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TB Screening Questionnaire for Students

The document is a tuberculosis (TB) screening questionnaire for incoming international students. It asks questions to assess risk factors for latent or active TB, including previous positive TB tests, BCG vaccination status, contact with TB patients, travel to or residence in high incidence countries, residence in high-risk settings, and membership in high-risk groups. Answering yes to any questions may require the student to receive TB testing upon arrival to campus.

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Pax Mardanica
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176 views1 page

TB Screening Questionnaire for Students

The document is a tuberculosis (TB) screening questionnaire for incoming international students. It asks questions to assess risk factors for latent or active TB, including previous positive TB tests, BCG vaccination status, contact with TB patients, travel to or residence in high incidence countries, residence in high-risk settings, and membership in high-risk groups. Answering yes to any questions may require the student to receive TB testing upon arrival to campus.

Uploaded by

Pax Mardanica
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Health Tuberculosis (TB) Screening Questionnaire

Services All Incoming International Students should complete

Name Student ID Date of Birth Today’s Date


920

Please answer the following questions by indicating Yes or No: YES NO


Have you ever had a positive TB skin test?
Have you ever been vaccinated with BCG?
Have you ever had close contact with persons known or suspected to have active TB disease?
Were you born in one of the countries or territories listed below that have a high incidence of active TB disease?
(If YES, please CIRCLE the country, below)
Have you had frequent or prolonged visits* to one or more of the countries or territories listed
below with a high prevalence of TB disease? (If yes, please CHECK the country/ies)
Have you been a resident and/or employee of high-risk congregate settings
(e.g. correctional facilities, long-term care facilities, homeless shelters)?
Have you been a volunteer or health care worker who served clients who are at
increased risk for active TB disease?
Have you ever been a member of any of the following groups that may have an increased
incidence of latent M. tuberculosis infection or active TB disease: medically underserved,
low-income, or abusing drugs or alcohol?

Afghanistan Columbia Iraq Nauru Singapore


Algeria Comoros Kazakhstan Nepal Somalia
Angola Congo Kenya New Caledonia South Africa
Anguilla Côte d'Ivoire Kiribati Nicaragua South Sudan
Argentina Democratic People’s Kuwait Niger Sri Lanka
Republic of Korea
Armenia Democratic Republic of the Kyrgyzstan Nigeria Sudan
Congo
Azerbaijan Djibouti Lao People's Democratic Northern Mariana Suriname
Republic
Bangladesh Dominican Republic Latvia Islands Swaziland
Belarus Ecuador Lesotho Pakistan Syrian Arab Republic
Belize El Salvador Liberia Palau Tajikistan
Benin Equatorial Guinea Libya Panama Tanzania (United
Republic of)
Bhutan Eritrea Lithuania Papua New Guinea Thailand
Bolivia (Plurinational State of) Ethiopia Madagascar Paraguay Timor-Leste
Bosnia and Herzegovina Fiji Malawi Peru Togo
Botswana Gabon Malaysia Philippines Tunisia
Brazil Gambia Maldives Portugal Turkmenistan
Brunei Darussalam Georgia Mali Qatar Tuvalu
Bulgaria Ghana Marshall Islands Republic of Korea Uganda
Burkina Faso Greenland Mauritania Republic of Moldova Ukraine
Burundi Guam Mauritius Romania Uruguay
Cabo Verde Guatemala Mexico Russian Federation Uzbekistan
Cambodia Guinea Micronesia (Federated Rwanda Vanuatu
States of)
Cameroon Guinea-Bissau Mongolia Sao Tome and Venezuela (Bolivarian
Principe Republic of)
Central African Republic Guyana Montenegro Senegal Viet Nam
Chad Haiti Morocco Serbia Yemen
China Honduras Mozambique Sierra Leone Zambia
China, Hong Kong SAR India Myanmar Serbia Zimbabwe
China, Macao SAR Indonesia Namibia Sierra Leone

Patient Signature_____________________________________________________________________
Health Services Medical Staff will review the answers you have provided and if any of the questions were answered “YES” will
request that you receive TB testing as soon as possible when you arrive on campus.

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