1. Have you ever had a positive (reactive) skin test or a positive TB blood test (IGRA: Quantiferon TB gold or T-spot)?
Yes
No
1b. What was the date of this test?
2. Have you ever received INH (Isoniazid), a medication given for a positive skin test?
Yes
No
3. In the past 6 weeks have you taken cortisone/steroid pills or injections?
Yes
No
4. Have you had a live vaccine (i.e., measles or chickenpox) in the past 4 weeks?
Yes
No
5. Are you currently experiencing any of the following symptoms? Check all that apply. * If you develop any of these symptoms (5a – 5f), contact Employee Health as soon as possible.
a. Cough lasting longer than 3 weeks
b. Fever
c. Night sweats (unrelated to weather or menopause)
d. Coughing/spitting blood
e. Unexplained fatigue
f. Unintentional weight loss > 10% of body weight
6. Do you work more than 10hrs per week in the health care facility?
Yes
No
7. Were you born in a country with an elevated TB rate (i.e., any country other than Australia, Canada, New Zealand, the United States, and those in western or northern Europe)?
Yes
No
8. Do you have a temporary or permanent residence (for ≥1 month) in a country with a high TB rate (i.e., any country other than Australia, Canada, New Zealand, the United States, and those in western or northern Europe)?
Yes
No
9. Do you have current or planned immunosuppression, including human immunodeficiency virus infection, receipt of an organ transplant, treatment with a TNF-alpha antagonist (e.g., infliximab, etanercept, or other), chronic steroids (equivalent of prednisone ≥15 mg/day for ≥1 month), or other immunosuppressive medication?
Yes
No
10. Have you had close contact with someone who has had infectious TB disease since the last TB test?
Yes
No
