TB Risk Assessment Questionnaire

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Please complete this short online form regarding your exposure to TB risk factors. Your responses will be transmitted securely to Kristen Hoogstra, District Nurse for SVUSD. Kristen will contact you to review the form, and advise you if anything further is needed for your TB clearance.

Email *

What is your full name? *

What is your phone number? *

What is your birthdate? *

YYYY

In what capacity will you be working? *

Have you ever had a documented positive TB test or a confirmed case of tuberculosis disease? *

Yes

Maybe

Have you experienced any of the following symptoms of TB (prolonged cough, coughing up blood, fever, night sweats, weight loss, or excessive fatigue)? *

Yes

Maybe

Were you born in a country with an elevated TB rate, or have you visited or lived in a country with elevated TB rates for at least 1 month (includes countries other than the United States, Canada, Australia, New Zealand, or Western and North European countries)? *

Yes

Maybe

Have you had close contact to someone with infectious TB disease during your lifetime? *

Yes

Maybe

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