Tuberculosis (TB) Questionnaire

In order to comply with the CDC's screening guidelines for healthcare workers, all volunteers must view the attached materials & answer the questionnaire below annually.

* Name (First & Last)
* Have you had temporary or permanent residency of 1 month or more in a country with a high Tuberculosis (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: