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Adult Tuberculosis (TB) Risk Assessment Questionnaire'

(To satisfy California Education Code Section 49406 and Health and Safety Code Sections 121525-121555)

To be administered by a licensed health care provider (physician, physician assistant, nurse, nurse practitioner)

Name:_____________________________________________________________________

Date of Birth: ______________________________Date of Risk Assessment:____________

History of positive TB test or TB disease Yes __ No __

If yes, a symptom review and chest x-ray (if none performed in previous 6 months) should be performed at initial hire.

If there is a "Yes" response to any of the questions #1-5 below, then a tuberculin skin test (TST) or Interferon Gamma Release Assay (IGRA) should be performed. A positive test should be followed by a chest x-ray, and if normal, treatment for TB infection considered.

Risk Factors

1. One or more signs and symptoms of TB (prolonged cough, coughing up blood, fever, night sweats, weight loss, excessive fatigue)

Note: A chest x-ray and/or sputum examination may be necessary to rule out infectious TB.2 Yes ___No ___

2. Close contact with someone with infectious TB disease Yes ___No ___

3. Foreign-born person Yes ___No ___

(Any country other than the United States, Canada, Australia, New Zealand, or a country in Western or Northern Europe.)

4. Traveler to high TB-prevalence country for more than 1 month Yes ___No ___

(Any country other than the United States, Canada, Australia, New Zealand, or a country in Western or Northern Europe.)

5. Current or former resident or employee of correctional facility, long-term care facility, hospital, or homeless shelter Yes ___No ___

Once a person has a documented positive test for TB infection that has been followed by an x-ray that was deemed free of infectious TB, the TB risk assessment is no longer required.

1 Adapted from a form developed by Minnesota Department of Health TB Prevention and Control Program and Centers for Disease Control and Prevention.

2. Centers for Disease Control and Prevention (CDC). Latent Tuberculosis Infection: A Guide for Primary Health Care Providers. 2013 (http://www.cdc.gov/tb/publications/LTBI/default.htm)

ADULT TUBERCULOSIS (TB) RISK ASSESSMENT QUESTIONNAIRE

CERTIFICATE OF COMPLETION

(To be signed by health care provider completing the risk assessment and/or examination)

Name: _____________________________________________________________________

Date of Birth: _______________________Date of Risk Assessment: ___________________

The above named patient has submitted to a tuberculosis risk assessment, and if tuberculosis risk factors were identified hos been examined and determined to be free of infectious tuberculosis.

___________________________________________________________________________

Health Care Provider Signature Date

___________________________________________________________________________

Health Care Provider Name Title

___________________________________________________________________________

Office Address: Street City State Zip Code

___________________________________________________________________________

Telephone Fax

Exhibit KINGSBURG ELEMENTARY CHARTER SCHOOL DISTRICT

version: September 19, 2016 Kingsburg, California

revised: October 13, 2016