Download Annual TB Screening Form

Tuberculosis/Respiratory Screening Form
PRINT CLEARLY
Today’s Date: ______________________________
LAST NAME: ______________________FIRST NAME: ______________
Department: _______________________ Birth Date: __________________
Employee Number: _________________ Job Title: ____________________
TST Symptom Review
Do you currently have symptoms of:
Productive cough of more than three weeks duration?
Blood present in sputum?
Unusual fatigue for more than two weeks?
Fever associated with cough for more than one week?
Night sweats?
Unexplained weight loss of eight pounds or more?
Loss of appetite for more than two weeks?
Do you have pain in the chest?
Current Health Status:
Do you have an acute viral infection or febrile illness?
Have you had a live-virus vaccine in the past 4-6 weeks?
Are you currently taking steroids (cortisone)?
Are you currently undergoing radiation therapy,
Chemotherapy or immunosuppressive therapy?
Do you have an allergy to LATEX?
History:
Have you ever had a TB skin test or QuantiFeron Gold blood test?
Have you ever had a positive reaction?
Have you had a recent chest x-ray?
*Have you traveled outside the US in the last 6 months?
*Have you had close contact with foreign born visitors in the last 6 months?
Is there anyone in your family with TB?
Have you ever had close contact with active TB?
Were you born in a country other than the United States?
Have you ever received a BCG vaccination?
Have you ever received INH (Isoniazid) therapy?
____ Employee
____ Annual
____ Medical Staff
____ Step 1 _____ Step 2
____ Volunteer
____ Exposure
____ Vendor/Contract Worker
Yes No If “Yes”, please explain
Drug Name/Dose:
Date:
Date:
Country?
*(Employee Health reviewed:____)
*(Employee Health reviewed:____________)
(Given outside of the U.S. for TB prevention)
(Treatment for TB)
PLEASE NOTE: TST’s MUST BE READ WITHIN 48 TO 72 HOURS AFTER BEING PLACED.
0.1 ml of 5 tuberculin units of purified protein derivative (PPD) given by intradermal Mantoux technique:
Date/Time Given:
Given By:
Site (circle)
Lot #
Serum Expiration
Left / Right Forearm
Date:
Date/Time Read
Read By
Induration
Print Name of TST Reader:
____________ m
Annual WISHA Respiratory Medical Evaluation Questionnaire
(This is mandatory for all employees who have patient contact or have the potential to have patient contact)
N-95 (Fitted Mask):
PAPR (Powered Air Purifying Respirator):
I CERTIFY THAT MY HEALTH STATUS HAS NOT CHANGED SINCE THE LAST RESPIRATOR MEDICAL EVALUATION.
Signature: __________________________________________________________________________ Date: __________________
Height: _____ ft. _____ in.
Weight: _____ lbs.
Age: ____
Sex: (circle one)
Male or Female
Do you smoke or currently use tobacco products? Yes____ No ____
For office use only (date and initial)
Placed OHM:
Read OHM
G-Drive
Release of Information: If you would like this completed form to be released to another employer or medical provider please sign below.
I hereby authorize Providence Employee Health Services-Everett to send this completed form to:
Facility: _________________________________________ Phone: ____________________ Fax: ___________________________
Sign Here: __________________________________________________________________ Date: __________________________
Update: 6/3/14 per KF/jk