TUBERCULOSIS (TB) SURVEILANCE EMPLOYEE FORM:

Name:_____________________________________ Dept_____________________________

DOB:______________________________________ Title:_____________________________

□ Pre-employment □ Annual □ Post Exposure □ Symptomatic □ Request

Please answer the following questions and sign at the bottom:

1. Have you had any of the following symptoms/signs associated with active Tuberculosis?

Yes No

A persistent cough longer than 2 weeks □ □

Unexplained weight loss □ □

Persistent night sweats □ □

Bloody sputum □ □

Chronic fatigue □ □

Fever □ □

2. Have had direct contact with a known case of Tuberculosis □ □

Name of person exposed to________________________Date___________________________

3. Have you ever had a positive TB skin test? (If yes, DO NOT TAKE PPD) □ □

When_________________________________________Where__________________________

4. Have you ever been treated for TB or positive TB test? □ □

When ________________________________________Where___________________________

5. Have you had a live virus vaccine (measles, mumps, rubella, varicella) in the past 6 weeks? ____

If yes, please allow 6 weeks before taking PPD test.

6. CDC does not recommend chest xrays for persons with history positive PPD test. Xrays are done on

Persons with new positive PPD or those with symptoms.

7. Have you taken BCG (Tuberculosis Vaccination) If yes, Do Not Take PPD □ □

______________________________________________________________________________________

Signature Date

TB test or PPD is a diagnostic screening test to aid in detecting possible infection with mycobacterium tuberculosis.

The test consists of a small injection of Tuberculin Purified Protein Derivative just under the skin of the forearm.

The test is read in 48-72 after injection. By signing below I give permission for test.

PPD Date Given:_______________Left Arm/Right Arm Given By:___________________________________________

Read Date___________Negative□ or ______mm Positive _____Allergic Reaction Read By_______________{___________}

Employee/Volunteer __________________________________________________________________________

Signature Date