Tuberculosis Screening Questionnaire

First Name:        Middle Initial:
Last Name:
Positive TB Skin Test (PPD) Date:
Last Chest X-Ray Date:
Please indicate if you have had any of the following problems for three to four weeks or longer:

Chronic Cough (greater than three weeks): Yes    No
Production of Sputum: Yes    No
Blood Streaked Sputum: Yes    No
Unexplained Weight Loss: Yes    No
Fever: Yes    No
Fatigue/Tiredness: Yes    No
Night Sweats: Yes    No
Shortness of Breath: Yes    No
  The information I have given is true and accurate AND THERE IS NO EVIDENCE OF PULMONARY TUBERCULOSIS OR CONTAGIUM. Applicants with negative TB skin test results or recent chest x-rays (less than 1 year) do not need the physician signed TB questionnaire. Please download PDF version of this form and print for Physician's signature if needed.
Date: