Risk Assessment Questionnaire - Department Of Public Health printable pdf download

Risk Assessment Questionnaire - Department Of Public Health

Pediatric TB Risk Assessment Questionnaire

A TB screening tool for healthcare providers only

The following questions are designed to determine whether a tuberculin skin test (TST) or Interferon Gamma Release Assay (IGRA) is indicated

for your pediatric patient. According to recent CDC guidelines, a TST is preferred for a child less than 5 years of age. If a child is 5 years of age or

older and is foreign-born, then an IGRA is preferred.

Name of Child: __________________________________________________________

Child’s Date of Birth: _____________________________

Date of Risk Assessment: ___________________________________

Questions to be asked of parent/guardian (adolescents can be asked directly):

1. Was your child born in a high-risk country?* Yes □ No □

2. Has your child traveled to a high-risk country* for more than 1 week? Yes □ No □

3. Has a family member or contact had tuberculosis disease? Yes □ No □

4. Has a family member had a positive TST or IGRA result? Yes □ No □

High-risk country: Any country other than the United States, Canada, Australia, New Zealand, or a country in

Western or Northern Europe

If there is a “Yes” response to any of the questions above, then TST or IGRA testing should be performed.

Note: If the child being screened was previously tested, had a documented negative TST or IGRA result, and has

not acquired any new risk factors since the last assessment, then he/she does not need to be re-tested.

Adapted from the Children’s Medical Services, Child Health and Disability Prevention Program Risk Assessment Questionnaire

Distributed in August 1, 2011 Provider Information Notice No. 11-04 Revised.

Centers for Disease Control and Prevention (CDC). Updated guidelines for using Interferon Gamma Release Assays to detect

Mycobacterium tuberculosis infection – United States, 2010. MMWR Morb Mortal Wkly Rep. June 25, 2010, Vol. 59, No. RR-5.

Updated 10.15.2012

Risk Assessment Questionnaire - Department Of Public Health

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