Student Health Record Siena College Page 4
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Required ONLY if answers to TB Screening Questions #1 and/or # 2 were “YES”
TUBERCULOSIS TESTING
STUDENT NAME:__________________________DOB:_______________
Categories of high risk students include those who have arrived within the past 5 years from countries listed below with a high incidence of active TB disease:
Afghanistan
Côte d'Ivoire
Kenya
Nicaragua
South Africa
Algeria
Democratic People's Republic of Korea
Kiribati
Niger
South Sudan
Angola
Democratic Republic of the Congo
Kuwait
Nigeria
Sri Lanka
Argentina
Djibouti
Kyrgyzstan
Niue
Sudan
Armenia
Dominican Republic
Lao People's Democratic Republic
Pakistan
Suriname
Azerbaijan
Ecuador
Latvia
Palau
Swaziland
Bahrain
El Salvador
Lesotho
Panama
Tajikistan
Bangladesh
Equatorial Guinea
Liberia
Papua New Guinea
Thailand
Belarus
Eritrea
Libya
Paraguay
Timor-Leste
Belize
Estonia
Lithuania
Peru
Togo
Benin
Ethiopia
Madagascar
Philippines
Trinidad and Tobago
Bhutan
Fiji
Malawi
Poland
Tunisia
Bolivia (Plurinational State of)
Gabon
Malaysia
Portugal
Turkey
Bosnia and Herzegovina
Gambia
Maldives
Qatar
Turkmenistan
Botswana
Georgia
Mali
Republic of Korea
Tuvalu
Brazil
Ghana
Marshall Islands
Republic of Moldova
Uganda
Brunei Darussalam
Guatemala
Mauritania
Romania
Ukraine
Bulgaria
Guinea
Mauritius
Russian Federation
United Republic of Tanzania
Burkina Faso
Guinea-Bissau
Mexico
Rwanda
Uruguay
Burundi
Guyana
Micronesia (Federated States of)
Saint Vincent and the
Uzbekistan
Cabo Verde
Haiti
Mongolia
Grenadines
Vanuatu
Cambodia
Honduras
Morocco
Sao Tome and Principe
Venezuela (Bolivarian
Cameroon
India
Mozambique
Senegal
Republic of)
Central African Republic
Indonesia
Myanmar
Serbia
Viet Nam
Chad
Iran (Islamic Republic of)
Namibia
Seychelles
Yemen
China
Iraq
Nauru
Sierra Leone
Zambia
Colombia
Kazakhstan
Nepal
Singapore
Zimbabwe
Comoros
Solomon Islands
Congo
Somalia
(Source: World Health Organization Global Health Observatory, Tuberculosis Incidence 2012. Countries with incidence rates of ≥ 20 cases per 100,000 population. For future updates, refer to )
Other categories of high risk students include those who have resided in, volunteered or worked in high –risk congregate settings such as prisons, nursing homes,
hospitals or homeless shelters, or a member of any of the following groups: medically underserved, low income or those abusing drugs and alcohol.
Required within 6 months of enrollment if indicated by YES to questions 1 and/or 2)
1. Tuberculin Skin Test (TST)
Date Placed: ______/______/______
Date Read: ______/______/______
Result: __________ (Record actual mm of induration)
Interpretation ( based on mm of induration as well as risk factors):
negative _____ positive___
OR
2. Interferon Gamma Release Assay (IGRA)
Date Obtained: ____/____/____ (specify method) QFT -GIT
T-Spot
other_____
Result: negative___ positive___ indeterminate___ borderline___ (T-Spot only)
3. Chest X-Ray (Required if TST or IGRA is positive)
Date of x-ray: ______/______/____
Result: Normal _____ Abnormal____
________________________________________________________________________________________________________________________
HEALTH CARE PROVIDER SIGNATURE REQUIRED:
Health Care Provider’s Signature___________________________________________________DATE_________________________________
PRINT NAME ______________________________________________________________________________________________________
ADDRESS__________________________________________________________________________________________________________
PHONE#____________________________________________________ FAX#__________________________________________________
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