Annual Tuberculosis Assessment Form.docx
DOCX document 16 KB Posted
- Attached to
- Chaplain Services
- Solicitation number
- 6100029089
- Issued by
- Chester County, Tharptown (uniontown) CDP, Pennsylvania
About this file
The document is an Annual Tuberculosis Assessment form used by an organization to screen employees for potential tuberculosis exposure or symptoms. The form includes a questionnaire that covers topics such as cough, weight loss, fever, and prior tuberculosis treatment or travel history. If any of the questions are answered affirmatively, the employee may be referred for further evaluation, which could include a chest X-ray and/or medication. The form is used to identify and manage tuberculosis cases in order to protect the health and safety of the organization's staff.
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Text version
ANNUAL TUBERCULOSIS ASSESSMENT
(For use with staff who are TST positive)
Please complete the following brief questionnaire about your health.
Do you currently have any of the following symptoms?
| Yes |
| No |
1. Cough lasting greater than 3 weeks?
2. Unexplained weight loss?
3. Loss of appetite?
4. Unexplained fever?
5. Night sweats?
6. Blood tinged sputum production?
7. Have you ever received BCG vaccine?
8. What is your country of origin?
9. Have you lived in any other country within the past 10 years?
10. Have you been treated for TB?
If yes to any question, please describe symptoms further. When did this start? Have you sought treatment? If yes, what treatment was done?
| Employee Signature |
| Date |
| Infection Control/Employee Health Nurse/Other |
| Date |
FOR OFFICE USE ONLY
Was this employee referred for further evaluation?
Yes
No
If yes, to whom?
Chest X-Ray?
Yes
No
Medication?
Yes
No
Work Restrictions?
Yes
No
If yes, describe:
Date:
File details come from the government source that posted it. Updated .