TB Form

TB FACT SHEET RISK AND SYMPTOM SCREEN

Tuberculosis (TB) Mycobacterium Tuberculosis is transmitted by air, carried in droplets that are created when a person with respiratory TB coughs, sneezes or shouts. TB Infection occurs when someone inhales the droplet particles containing the Mycobacterium. A person may have no symptoms, but still have latent TB infection (LTBI) and may develop TB disease at some point in their lives. TB skin tests may become positive in 2 to 12 weeks after the exposure. Risk Factors Check if any of the following risk factors apply to you: Groups with a higher risk of exposure and infection*

RISK FACTORS: Check if any of the following risk factors apply to you: Groups with a higher risk of exposure and infection*

Low income/medically under served populations
Residents or employees of congregate living facilities such as homeless shelters, long-term care facilities and correctional facilities
Infants, children or adolescents who are exposed to adults in high-risk categories
Foreign-born persons recently arrived (within 5 years) from areas with a high incidence of TB, such as Asia, Africa, Eastern Europe, Latin America and Russia, or those who frequently travel to areas with a high incidence of TB
Close contacts with individuals with pulmonary TB persons who inject illicit drugs or other locally identified high-risk substance users (e.g., crack cocaine users) *Flexibility is needed in defining local high-priority groups for screening

Groups with a greater risk to progress from latent TB infection to active disease

Individuals with HIV infection, silicosis, diabetes, chronic renal failure, and those more than 10% below normal body weight, hematologic disorders (e.g., leukemias and lymphomas), other specific malignancies (e.g., carcinoma of the head or neck),
Those receiving some medical treatments that may increase risks, such as prolonged corticosteroid use, or other immunosuppressive treatments, bone marrow or organ transplant, intestinal bypass or gastrectomy
Persons with a history of untreated or inadequately treated TB disease

Signs and Symptoms of TB Disease in the Lungs* Check if you currently have any of the following symptoms:

Name*

First Name Last Name

I understand if I am experiencing any of the above symptoms, followup will be required. I understand if I have any of the above symptoms at any time in the future, I am to report to management immediately and follow-up will be required at that time.

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