Student Full Name Student Date of Birth

Student Full Name Student Date of Birth

Student Address, City, State, Zip

Tuberculosis:Student - tell your provider if you have received the BCG vaccine and if so, when you received it. (This vaccine is only given outside of the United States.) Also tell your provider if you have a history of a positive TB test.

Requirement: Negative TB blood test (QuantiFeron®-TB GOLD [QFT-GIT] or T-SPOT® TB Test) completed within the last year.

---OR—

Requirement: Negative (0-<5 mm)two-step purified protein derivative (PPD) completed within the last year. The Center for Disease Control and Prevention recommends the first test be administered and then evaluated (read) 48-72 hours later, no earlier and no later. A minimum of 7 days after and maximum of 21 days after the administration of the first test, the second test can be administered. The second test is evaluated 48-72 hours later

---OR FOR POSITIVE PPD ONLY--

For students with a past positive PPD, a negative chest x-ray (no evidence of active pulmonary disease) is required once. Chest x-rays are only acceptable if taken as a follow up to a previous or current positive TB skin test.

CSP Nursing Annual Tuberculosis Questionnaire (required only if indicated)

Check box if not applicable (chest xray is not required)

The Annual Tuberculosis (TB) Questionnaire is used to evaluate your current TB status. We cannot utilize the tuberculin skin test (PPD or Mantoux), because you have a positive reaction to the test. A positive skin test means that sometime during your life you came into contact with tuberculosis or have had a vaccination to prevent you from contracting tuberculosis. It does not mean that you have TB now.

In the past, yearly chest x-rays were performed; however, recent studies show that they are unnecessary. Instead, this health survey will assist your provider to monitor possible TB Symptoms. TB symptoms can progress slowly and/or mimic other diseases. You can develop symptoms of TB a few weeks after contracting the bacteria – or not until years after the initial infection. This questionnaire targets some of the most common symptoms. Please familiarize yourself with them. You are the first to know when you are not feeling well and may have TB symptoms.

Tuberculosis Health Check Survey

Have you ever experienced any of the following symptoms NOT associated with a specific illness (i.e. flu or cold) and lasting 3 weeks or longer?

Cough Yes No

HoarsenessYes No

Blood Streaked Sputum (phlegm) Yes No

Loss of Weight (unplanned/unexplained) Yes No

Night Sweats Yes No

Fever/chillsYes No

Anorexia (loss of appetite) Yes No

Unexplained Fatigue (tiredness)YesNo

Chest PainYesNo

This authorization will expire one year from the dated signature below.

______

Student Name PrintedStudent SignatureDate

Verification of TB Status by Healthcare Provider or Nurse

All tuberculosis status dates above are hereby certified and all other medical records of this student are on file at the physician/provider’s office.

Signature of Provider or Nurse Date

Name of Provider or Nurse – Please print Credentials – Please Print

Clinic Name and Address

Clinic Telephone Number

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