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By completing this Questionnaire, you attest that you have had a positive/sensitive TB skin test that your physician/NP/PA has deemed you ineligible for the TB skin test due to medical reasons or that completion of the form is a state or client requirement. Therefore upon hire and annually thereafter you are required to complete this Questionnaire. For positive/sensitive TB skin tests: Please submit a current, clear chest x-ray upon hire.


Have you ever been treated for latent TB infection?
Have you ever been treated for active TB disease?

Please read and put a checkmark in the correct Yes/No space if you are experiencing any of
the following symptoms or if any of the following apply to you:


1. Unplanned loss of weight (>10% of body weight)
2. Night sweats
3. Fever lasting several weeks
4. Frequent coughing in the absence of a cold or flu
5. Production of sputum
6. Coughing blood-streaked sputum
7. Unusual tiredness or weakness lasting weeks
8. Shortness of breath
9. Pain in chest when taking a breath
10. Have you been recently diagnosed with diabetes, silicosis, HIV disease, renal disease or liver disease?
11. Have you been recently exposed to a family member or others with active TB?
If you checked YES to any of the above symptom questions, is a physician currently treating you?

If you develop any of the symptoms listed above, please contact your physician and agency immediately. A chest x-ray must be performed prior to working again.

Thanks for submitting!

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