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Assisted Living
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On-Site Healthcare Services
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TB Attestation Form
Application Form
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Tb Targeted Medical Questionnaire And Risk Form
Employee Printed Name
1. Have you ever had a positive TB skin test or history of TB infection?
Yes
No
If the answer is YES, please answer the following:
2. Have you ever had the BCG vaccine?
Yes
No
3. Do you have prolonged or recurrent fever?
Yes
No
4. Have you recently lost weight?
Yes
No
5. Do you have a chronic cough?
Yes
No
6. Do you cough up blood?
Yes
No
7. Do you have sweating at night?
Yes
No
8. Do you have any of the following risk factors
a. Silicosis (lung disease)
b. Gastrectomy
c. Intestinal Bypass
d. Weight 10% or more below ideal body weight
e. Chronic Renal Disease
f. Diabetes Mellitus
g. Prolonged high-dose corticosteroid therapy or other Immunosuppressive therapy
h. Hematologic Disorder i.e. leukemia or lymphoma
i. Exposure to HIV or AIDS
j. Other malignancies
Baseline Individual TB Risk Assessment
Answer “Yes” or “No”. Employee should be considered at risk for TB if any of the following statements are marked “Yes”.
Temporary or permanent residence of > 1 month in a country with a high TB rate (any country other than the U.S., Canada, Australia, New Zealand, and those in Northern or Western Europe)
Current or planned immunosuppression, including HIV infection, organ transplant recipient, treatment with a TNF alpha antagonist, chronic steroids, or other immunosuppressive medication.
Close contact with someone who has had infectious TB disease since the last TB test
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