EMPLOYEES HEALTH TB SCREEN - Columbia Memorial Health

Name*

First Last

D.O.B.*

Date*

Position*

Dept/Office*

Phone*

Select One*

Employee
Volunteer
Contract Employee

TB Exposure: Have you been exposed to anyone with active TB in the past year*

Yes
Not that I am aware of
Possibly

TB Test History*

Positive PPD
Positive PPD, Negative QuantiFERON GOLD blood test prior to hire
Positive PPD, Negative Chest X-Ray prior to hire
Hx of Prior TB or TB Exposure Treatment
Completing this in place of PPD due to current shortage

Other

Select all that apply

I am a diabetic
I have a history of blood/lymphatic disease (such as Leukemia, Hodgkins)
I take corticosteroids such as prednisone, Decadron or other steroids.
I take immunosuppressive drugs (azathioprine, cyclosporine, muromonab, etc.)

Have you experienced any of these symptoms in the past year? (Select all that apply)*

Are these symptoms current or old?

**I understand the signs & symptoms of TB and that I am at increased risk, and therefore will notify my supervisor if I develop any of these symptoms.*

(Employee Initials)

Signature of Applicant*

Date*

Consent*

By checking this box I acknowledge all the information I have included in this form is true to the best of my knowledge.

Date of last negative chest x-ray:

File

Max. file size: 200 MB.

Date of last negative QuantiFERON GOLD blood test:

Admin Use Only

Select One:

Cleared
Not Cleared, Medical Director has been notified

Provider Name Printed

Provided Signature

Date

EMPLOYEE HEALTH TB SCREEN

Admin Use Only