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University of Illinois at Urbana-Champaign
Tuberculosis Screening Declination
Employee Name: ___________________________________
Date: ____________________
University Identification Number (UIN): ____________________________________________________
Employee Occupation/Title: ______________________________________________________________
Employer Representative (PI/Unit Head): ___________________________________________________
Employee: Please check the appropriate box:
Decline: I understand that due to my occupational exposure to blood or other potentially
infectious materials I may be at risk of acquiring tuberculosis infection. I have been given the
opportunity to be screened for tuberculosis, at a cost of $5.00. However, I decline screening at
this time:
I have received the BCG vaccine within the past three years
I have a history of a positive reaction to a previous tuberculin skin test, a documented
history of infection, or treatment for TB per CDC guidelines.
I have a history of infection with a positive skin reaction and without treatment.
I understand that by declining this screening, I continue to be at risk of acquiring tuberculosis, a serious
disease. If in the future I continue to have occupational exposure to blood or other potentially infectious
materials and I want to be screened for tuberculosis, I can receive the screening and agree to associated
cost of $5.
I choose to be screened at a cost of $5, or having been elsewhere in the last 12 months and will
provide appropriate documentation.
Employee Signature: ______________________________________
Date: _____________________
For more information, see the DRS fact sheet entitled; Frequently Asked Questions about Hepatitis B
Vaccination (
PI/Unit Head
Signature: ______________________________________________
Date: _____________________
*PI/Unit Head as defined in the UIUC Bloodborne Pathogens Exposure Control Plan
Updated Feb 2014