TB Risk & Symptom Assessment

Please complete the form below as part of our annual TB documentation requirements.
If you have any questions please contact the office during normal business hours.
You must choose an answer for all questions.
Have you:
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ever had a positive reaction to a TB skin test
been in close contact with someone who has had infectious TB since your last TB test
lived in a country with a high TB rate for more than 1 month
received or planning to receive immunosuppressive treatment
ever had or been treated for exposure to TB
been exposed to a communicable pulmonary disease in the past 2 yrs
and have you experienced any of the following:
recent unexplained weight loss
pain in the chest
bad coughing lasting more than 3 weeks
coughing up blood
weakness or fatigue
loss of appetite
fever / chills / night sweats

Electronically sign your form:

By entering the following electronic signature & clicking "submit" you attest to the following statements:

I have answered the above questions truthfully and to the best of my ability. I understand that depending on my answers No Place Like Home may require additional screening and or medical evaluation to establish my TB risk as part of my continued employment.

If there are any changes in the information answered above I understand it is my duty to seek appropriate medical attention and to notify No Place Like Home administration.

Agreement *
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