In order to comply with the CDC's screening guidelines for healthcare workers,

all volunteers must view the attached materials and answer the questionnaire below annually.

Please view the CDC's educational fact sheet HERE.

Please view the MMWR's screening and treatment guidelines HERE.

* First and last name
* Have you had temporary or permanent residency of one month or more in a country with a high TB rate? (Excludes: US, Canada, Australia, New Zealand, and those in Northern or Western Europe)
* Do you have a current or planned immunosuppression? (Including HIV, organ transplant recipient, treatment with a TNF-alpha antagonist - infliximab, etanercept or other, chronic steroids equivalent of more than 15 mg/day of prednisone for more than 1 month or other immunosuppressive medication)
* Have you had close contact with someone who has had infectious TB disease since the last TB test?
* Do you have a history of a prior positive TB skin test?
If you answered YES to any of the above questions, please check any of the following symptoms you have had:

Adapted from:  

CDC Signs & Symptoms of TB Disease;

CDC HCP Baseline Individual TB Risk Assessment: Health Care Personnel (HCP) Baseline Individual TB Risk Assessment (