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TB Assessment Questions
Please answer the following questions
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Email
*
Your email
Today's Date
*
MM
/
DD
/
YYYY
First Name
*
Your answer
Last Name
*
Your answer
Site
*
Your answer
Job Description /Student ID#/Volunteer
*
Your answer
DOB
*
MM
/
DD
/
YYYY
Have you ever had a POSITIVE TB test? NO
*
Yes
No
Birth, travel, or residence outside the US for >30 days?
*
Yes
No
Hang out with anyone that has TB?
*
Yes
No
Having any symptoms now...coughing up blood, night sweats, excessive fatigue, shortness of breath, anything scary?
*
Yes
No
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