Federal Occupational Health

Tuberculosis Screening
Name:
_____________________________________________________________

SSN#
______________________

Male
Female

Agency: ________________________

Job Title
______________________

Date:
__________

Location/City: _______________

Work Phone: ____________________

Birthdate: ______________

Please circle the appropriate answer below for each question. This information is strictly confidential and
will only be used to determine the proper test and reading procedures.
FOR FOH USE ONLY
1. Have you ever had positive TB skin test?

YES

NO

2. Are you currently taking steroids (other than

inhalers), chemotherapy, cancer treating drugs, or
have you tested HIV+)?

YES

NO

YES

NO

3. Do you have a current viral infection (e.g., flu, measles, etc.)

or have you received a live virus vaccination in the last
6 weeks (e.g., yellow fever, oral polio, MMR - measles,
mumps, rubella)?
4. Do you currently have symptoms of tuberculosis?
a. Coughing up blood for 2-3 weeks OR
b. Do you have two or more of the following?
Chronic cough
Soaking night sweats
Chronic fatigue
Weight loss
Fever (>100)

If YES, DO NOT TEST

If symptoms of TB (see Q#4.)
refer to PMD for evaluation
If YES, DO NOT TEST
Refer to PMD for evaluation

If YES, DEFER TESTING

Save form and plan to test client
after well for 6 weeks.
.

YES

NO

YES

NO

YES

NO

7. Were you born in Asia, Africa, Latin America, or the

Caribbean?

YES

NO

8. Do you have any of the following?

Diabetes
Cancer
Silicosis
Gastrectomy
Underweight
Kidney failure

YES

NO

5. Do you or have you had any of the following:

Blood transfusion before 1985?
Multiple sex partners?
Same sex partners (i.e., male/male)?
Contaminated needle stick?
Use injectable drugs?
6. Have you had household or similar close contact with
someone who is known to have active TB in the last 3
months?

TEST
If YES, Refer to PMD for
evaluation;
Consult FOH POC regarding
employee return to work.

TEST
If YES, read test
positive @ 5mm..

TEST
If YES, read test
positive @ 10mm..

TEST
Read test positive @ 15mm..

If all NO

RESULTS: FOR FOH USE ONLY

Initial PPD Results

Post-exposure

Check ONE:

FOH Health Center (stamp)

2nd PPD Results

age > 55

Client declined

Date applied:_______________ L/R

Date applied: _______________ L/R

PPD NOT indicated (Pos. Hx.)

Applied by ___________________

Applied by ___________________

Baseline FOH PPD

FOH

other provider

FOH

other provider

Periodic FOH PPD

Manufacturer:_________________

Manufacturer:_________________

PPD Post-exposure OR

Lot#___________ Exp._________

Lot#___________ Exp._________

baseline for > age 55 (requires 2 PPDs)

Date read: ___________________

Date read: ___________________

Read by: ____________________

Read by: ____________________

_________mm. induration

_________mm. induration

Check if applicable:
Client referred
Client did not return for reading

Positive (referred)

Negative

Positive (referred)

Negative

This form is presented as a guide and should not replace professional clinical judgment. For additional information please refer to FOH Tuberculosis Orientation: A Self Study Guide
FOH-25

Rev.5/11/99