TB Annual Health Review Form


HAWAII PACIFIC HEALTH TB Annual Health Review Form

Please complete the following form, we ask that you provide accurate responses. If you have questions or need assistance with completing the form, please contact employee health at 529-4905.

PERSONAL INFORMATION (Please provide the following information):

Are you an HPH Employee?
Are you a Clinical Labs of Hawaii (CLH) employee?

Please answer the following questions:

1. Have you ever had a positive (reactive) skin test or a positive TB blood test (IGRA: Quantiferon TB gold or T-spot)?
2. Have you ever received INH (Isoniazid), a medication given for a positive skin test?
3. In the past 6 weeks have you taken cortisone/steroid pills or injections?
4. Have you had a live vaccine (i.e., measles or chickenpox) in the past 4 weeks?
5. Do you work more than 10hrs per week in the health care facility?
6. In the past 12 months have you experienced any of the following symptoms? Check all that apply.
* If you develop any of these symptoms (6a – 6f), contact Employee Health as soon as possible.
7. Were you born in a country with a high rate of TB? (This means any country other than Australia, Canada, New Zealand, the United States, Great Britain, France, Spain, Portugal, Germany, Norway, Sweden, Denmark, and Japan)?
8. Since your last TB evaluation, have you lived in or traveled to a country with a high rate of TB (for three weeks or longer)? (This includes any country other than Australia, Canada, New Zealand, the United States, Great Britain, France, Spain, Portugal, Germany, Norway, Sweden, Denmark, and Japan)?
9. Since your last TB evaluation, have you lived with someone who was born in a country with a high rate of TB? (This means any country other than Australia, Canada, New Zealand, the United States, Great Britain, France, Spain, Portugal, Germany, Norway, Sweden, Denmark, and Japan)?
10. Since your last TB evaluation, has anyone visited your home for three weeks or longer who was from a country with a high rate of TB? (This means any country other than Australia, Canada, New Zealand, the United States, Great Britain, France, Spain, Portugal, Germany, Norway, Sweden, Denmark, and Japan)?
11. Do you have a health problem that affects your immune system, including human immunodeficiency virus (HIV/AIDS), transplant recipient, cancer requiring radiation or chemotherapy?
12. Do you have medical treatment planned that may affect your immune system, including treatment with a TNF-alpha antagonist (e.g., Humira, Enbrel, Remicade, or other), chemotherapy, chronic steroids (equivalent of prednisone at 15 mg or more per day for one month or longer), or other immunosuppressive medication?
13. Have you had close contact with someone who has had infectious TB disease since your last TB evaluation?

Please review your answers carefully before submitting. You may only submit this form once per annual requirement. If you need to make any changes after submitting your form, you must contact Employee Health at (808) 529-4900 to speak with a nurse for assistance.

Once submitted, this form cannot be edited or resubmitted online.

I confirm that the information I have provided is accurate to the best of my knowledge.

For Credentialed Providers Only: By submitting this form, I authorize HPH to share my TB clearance information with HPH affiliates, entities, and Medical Staff Offices where I hold or seek privileges. This consent remains valid for the duration of my employment or affiliation.

I understand that my electronic signature is the legal equivalent of my manual/handwritten signature.