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University of Maine at Farmington Tuberculosis Screening Form
If you answer NO to all questions, no further action will be needed. If you answer YES to any question, you will need to have a TB skin screening test at the UMF Student Health Center upon arrival, or provide documentation of a negative TB test result.
* Indicates required question
Email
*
Record my email address with my response
First/Given Name
*
Your answer
Last/Surname
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
To the best of your knowledge have you ever had close contact with anyone who was sick with tuberculosis (TB)?
*
Yes
No
Have you ever had a positive (reactive) TB skin test?
*
Yes
No
Were you born in any country
other than
Australia, Canada, Japan, New Zealand, United States, or Western European countries?
*
Yes
No
Have you traveled or lived for more than one month in any country
other than
Australia, Canada, Japan, New Zealand, United States, Western European countries, or lived on an Indian reservation in the United States?
*
Yes
No
Have you ever lived or worked in a homeless shelter or prison?
*
Yes
No
If you answered Yes to any of the above questions, please explain in detail.
Your answer
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