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TB Pre-employment Screening Questionnaire

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Section 1: TB Risk Assessment
Temporary or permanent residence of more than 1 month in a country with a high TB rate.
(Any country other than USA, Canada, Australia, New Zealand, and those in the Northern Europe or Western Europe)
Current or planned immunosuppression.
(including human immunodeficiency virus (HIV) infection, organ transplant recipient, treatment with a TNF-alpha antagonist (e.g., infliximab, etanercept, or other), chronic steroids (equivalent of prednisone ≥15 mg/day for ≥1 month) or other immunosuppressive medication)
Close contact with someone who has had infectious TB disease since the last test
Section 2: Symptoms Screening
Do you currently have a cough that has lasted longer than 3 weeks?
Do you cough up blood or mucous?
If yes, have you recently had the mucous you cough up tested for TB?
If yes, were you told it was positive?
Have you had a decrease in appetite? Are not hungry?
Have you lost weight (over 10 lbs.) in the last 2 months without trying?
Do you have night sweats (need to change the sheets or you bed clothes)?
Do you have pain in the chest

I certify that to the best of my knowledge the all the above statements are correct.

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