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ANNUAL TUBERCULOSIS QUESTIONNAIRE FOR ANY EMPLOYEE WHO HAS TESTED POSITIVE FOR TB IN THE PAST

This questionnaire is a EZ Healthcare of Boston Group, LLC annual employment requirement for any employee who reports that they have tested PPD positive at any time in the past. The questionnaire is a method to monitor infection control and reportable diseases. The incidence of TB and drug resistant strains of TB is an increasing occurrence in the USA.

TB History

Early Detection of Tuberculosis
This questionnaire gives guidance in identifying individuals with suspected or confirmed TB so that appropriate controls can be promptly initiated.

The questionnaire has two parts:
1. Reviewing the individual's TB history
2. Assessing current symptoms

INSTRUCTIONS:
  • Circle each answer given by employee.
  • Add your comments as the evaluator at the bottom of the page.
  • Institute AMS exposure control measures outlined in AMS Exposure Control Plan,
  • Respiratory Protection and Medical Surveillance Program and refer the individual for further evaluation if the individual has:
(1) A persistent cough lasting 3 or more weeks and two or more symptoms of active TB.
(2) Had a positive TB test on mucous that he/she coughed up.
(3) Been told that he/she had TB and was treated, but never finished the medication.
TB HISTORY (Part 1)
1. Have you ever had a positive TB skin test?
Yes No Don/t Know
2. Have you ever had an abnormal chest x-ray?
Yes No Don/t Know
If yes, how long ago?
3. Have you recently had the mucous you cough up tested for TB?
Yes No Don/t Know
3. Have you recently had the mucous you cough up tested for TB?
Yes No Don/t Know
If yes, were you told it was positive?
4. Have you ever been told you have Infectious Tuberculosis?
Yes No Don/t Know
If yes, how long ago?
5. Have you ever been treated with medication for Infectious TB?
Yes No Don/t Know
If yes, how may medications?
One Two Over Two
6. Are you still taking TB medicine?
Yes No
Did you take all the TB medicine until the health care professional told you that you were finished?
Yes No
7. Do you live with or have you been in close contact with someone who was recently diagnosed with TB? (e.g. shelter roommate, close friend, relative).
Yes No Don/t Know
Did you take all the TB medicine until the health care professional told you that you were finished?
Yes No
CURRENT SYMPTOMS (Part Two)
1. Do you have a cough that has lasted longer than three weeks?
Yes No
2. Do you cough up blood or mucous?
Yes No
3. Have you lost your appetite? Aren't hungry?
Yes No
3. Have you recently had the mucous you cough up tested for TB?
Yes No Don/t Know
4. Have you lost weight (more than 10 pounds) in the last two months? Without trying to?
Yes No
5. Do you have night sweats (need to change the sheets or your clothes because they are wet)?
Yes No
Evaluator Comments:
Exposure Control Methods Implemented?
Yes No
Referred for Further Evaluation?
Yes No
Evaluators Signature Date

Unless contraindicated a purified protein derivative (PPD) of the tubercle bacillus is injected intradermally. Immunosuppressed individuals or other health conditions may cause a TB skin test to be negative when an actual TB infection is present. Interpretation of a result and varied induration of "X" mm is based on risk factors

 
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