Download TB form

Survey
yes no Was this document useful for you?
   Thank you for your participation!

* Your assessment is very important for improving the work of artificial intelligence, which forms the content of this project

Document related concepts

Urinary tract infection wikipedia, lookup

Common cold wikipedia, lookup

Traveler's diarrhea wikipedia, lookup

Sociality and disease transmission wikipedia, lookup

Globalization and disease wikipedia, lookup

Vaccination wikipedia, lookup

Schistosomiasis wikipedia, lookup

Childhood immunizations in the United States wikipedia, lookup

Hospital-acquired infection wikipedia, lookup

Neonatal infection wikipedia, lookup

Hygiene hypothesis wikipedia, lookup

Infection wikipedia, lookup

Hepatitis B wikipedia, lookup

Hepatitis C wikipedia, lookup

Infection control wikipedia, lookup

Tuberculosis wikipedia, lookup

Transcript
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 (http://www.drs.illinois.edu/bss/factsheets/hepb.aspx?tbID=fs).
PI/Unit Head
Signature: ______________________________________________
Date: _____________________
*PI/Unit Head as defined in the UIUC Bloodborne Pathogens Exposure Control Plan
Updated Feb 2014