Form MO580-3015 "Tuberculosis (Tb) Risk Assessment Form" - Missouri

What Is Form MO580-3015?

This is a legal form that was released by the Missouri Department of Health and Senior Services - a government authority operating within Missouri. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2014;
  • The latest edition provided by the Missouri Department of Health and Senior Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form MO580-3015 by clicking the link below or browse more documents and templates provided by the Missouri Department of Health and Senior Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form MO580-3015 "Tuberculosis (Tb) Risk Assessment Form" - Missouri

396 times
Rate (4.7 / 5) 23 votes
Missouri Department of Health and Senior Services
Bureau of Communicable Disease Control and Prevention
Tuberculosis (TB) Risk Assessment Form
Patient’s Name: __________________________________ Date of Birth:______________ Date: _______________
Address: _________________________________________________ Phone Number: _______________________
A. Please answer the following questions (Sections A & B to be completed by Patient):
Have you ever had a positive Mantoux tuberculin skin test (TST)?
Yes
No
Have you ever been vaccinated with BCG?
Yes
No
Have you ever had a positive Interferon Gamma Release Assay (IGRA) test?
Yes
No
Have you ever been diagnosed with or treated for TB Disease?
Yes
No
B. TB Risk Assessment
Have you ever had close contact with anyone who was sick with tuberculosis?
Yes
No
Have you ever traveled to one or more of the countries listed below? If yes, please CHECK the countries.
Yes
No
Were you born in one of the countries listed below? If yes, please list the country:____________________
Yes
No
What year did you arrive in the United States? _____________
Afghanistan
Cape Verde
Gabon
Kuwait
Myanmar
St. Vincent &
Tokelau
Algeria
Central African Rep.
Gambia
Kyrgyzstan
Namibia
The Grenadines
Tonga
Angola
Chad
Georgia
Lao PDR
Nauru
Sao Tome & Principe
Trinidad & Tobago
Anguilla
Chile
Ghana
Latvia
Nepal
Saudi Arabia
Tunisia
Argentina
China
Greenland
Lesotho
Nicaragua
Senegal
Turkey
Armenia
Colombia
Guatemala
Liberia
Niger
Serbia
Turkmenistan
Azerbaijan
Comoros
Guinea
Libyan Arab Jamihirya
Nigeria
Seychelles Sierra
Turks & Caicos
Bahrain
Congo
Guinea-Bissau
Lithuania
Niue
Leone
Islands
Bangladesh
Congo DR
Guam
Macedonia-TFYR
Northern Mariana
Singapore
Tuvalu
Belarus
Cote d’Ivoire
Guyana
Madagascar
Islands
Solomon Islands
Uganda
Belize
Croatia
Haiti
Malawi
Pakistan
Somalia
Ukraine
Benin
Djibouti
Honduras
Malaysia
Palau
South Africa
Uruguay
Bhutan
Dominica
Hungary
Maldives
Panama
Sri Lanka
Uzbekistan
Bolivia
Dominican Republic
India
Mali
Papua New Guinea
Sudan
Vanuatu
Bosnia & Herzegovina
Ecuador
Indonesia
Marshall Islands
Paraguay
Sudan - South
Venezuela
Botswana
Egypt
Iran
Mauritania
Peru
Suriname
Viet Nam
Brazil
El Salvador
Iraq
Mauritius
Philippines
Syrian Arab Republic
Wallis & Futuna
Brunei Darussalam
Equatorial Guinea
Japan
Mexico
Poland
Swaziland
Islands
Bulgaria
Eritrea
Kazakhstan
Micronesia
Portugal
Tajikistan
Yemen
Burkina Faso
Estonia
Kenya
Moldova-Rep.
Qatar
Tanzania-UR
Zambia
Burundi
Ethiopia
Kiribati
Mongolia
Romania
Thailand
Zimbabwe
Cambodia
Fiji
Korea-DPR
Morocco
Russian Federation
Timor-Leste
Cameroon
French Polynesia
Korea-Republic
Mozambique
Rwanda
Togo
Source: World Health Organization Global Tuberculosis Control, WHO Report 2013, Countries with Tuberculosis incidence rates of > 20 cases per 100,000
population. For future updates, refer to http://www.who.int/topics/tuberculosis/en/.
Have you ever had an abnormal chest x-ray suggestive of TB?
Yes
No
No Response
Yes
No
No Response
Are you HIV positive?
Yes
No
No Response
Are you an organ transplant recipient or donor?
Yes
No
No Response
Are you immunosuppressed (taking an equivalent of > 15 mg/day of prednisone for >1 month, or
currently taking prescription arthritis medication)?
Are you a resident, employee, or volunteer in a high-risk congregate setting (e.g., correctional
Yes
No
No Response
facilities, nursing homes, homeless shelters, hospitals, and other health care facilities)?
Do you have any medical conditions such as diabetes, silicosis, head, neck, or lung cancer,
Yes
No
No Response
hematologic or reticuloendothelial disease such as Hodgkin’s disease or leukemia, end stage
renal disease, intestinal bypass or gastrectomy, chronic malabsorption syndrome, low body
weight (i.e., 10% or more below ideal)?
Do you have a cough lasting 3 weeks or longer, chest pain, weakness or fatigue, weight loss,
Yes
No
No Response
chills, fever and/or night sweats?
Yes
No
No Response
Are you coughing up blood or phlegm?
I hereby certify that this application contains no misrepresentation or falsification and that the information given by me is true and complete to the
best of my knowledge and belief.
______________________________________
_____________________________________
Patient Signature
Date:
(Required)
MO 580-3015 (03-14)
Missouri Department of Health and Senior Services
Bureau of Communicable Disease Control and Prevention
Tuberculosis (TB) Risk Assessment Form
Patient’s Name: __________________________________ Date of Birth:______________ Date: _______________
Address: _________________________________________________ Phone Number: _______________________
A. Please answer the following questions (Sections A & B to be completed by Patient):
Have you ever had a positive Mantoux tuberculin skin test (TST)?
Yes
No
Have you ever been vaccinated with BCG?
Yes
No
Have you ever had a positive Interferon Gamma Release Assay (IGRA) test?
Yes
No
Have you ever been diagnosed with or treated for TB Disease?
Yes
No
B. TB Risk Assessment
Have you ever had close contact with anyone who was sick with tuberculosis?
Yes
No
Have you ever traveled to one or more of the countries listed below? If yes, please CHECK the countries.
Yes
No
Were you born in one of the countries listed below? If yes, please list the country:____________________
Yes
No
What year did you arrive in the United States? _____________
Afghanistan
Cape Verde
Gabon
Kuwait
Myanmar
St. Vincent &
Tokelau
Algeria
Central African Rep.
Gambia
Kyrgyzstan
Namibia
The Grenadines
Tonga
Angola
Chad
Georgia
Lao PDR
Nauru
Sao Tome & Principe
Trinidad & Tobago
Anguilla
Chile
Ghana
Latvia
Nepal
Saudi Arabia
Tunisia
Argentina
China
Greenland
Lesotho
Nicaragua
Senegal
Turkey
Armenia
Colombia
Guatemala
Liberia
Niger
Serbia
Turkmenistan
Azerbaijan
Comoros
Guinea
Libyan Arab Jamihirya
Nigeria
Seychelles Sierra
Turks & Caicos
Bahrain
Congo
Guinea-Bissau
Lithuania
Niue
Leone
Islands
Bangladesh
Congo DR
Guam
Macedonia-TFYR
Northern Mariana
Singapore
Tuvalu
Belarus
Cote d’Ivoire
Guyana
Madagascar
Islands
Solomon Islands
Uganda
Belize
Croatia
Haiti
Malawi
Pakistan
Somalia
Ukraine
Benin
Djibouti
Honduras
Malaysia
Palau
South Africa
Uruguay
Bhutan
Dominica
Hungary
Maldives
Panama
Sri Lanka
Uzbekistan
Bolivia
Dominican Republic
India
Mali
Papua New Guinea
Sudan
Vanuatu
Bosnia & Herzegovina
Ecuador
Indonesia
Marshall Islands
Paraguay
Sudan - South
Venezuela
Botswana
Egypt
Iran
Mauritania
Peru
Suriname
Viet Nam
Brazil
El Salvador
Iraq
Mauritius
Philippines
Syrian Arab Republic
Wallis & Futuna
Brunei Darussalam
Equatorial Guinea
Japan
Mexico
Poland
Swaziland
Islands
Bulgaria
Eritrea
Kazakhstan
Micronesia
Portugal
Tajikistan
Yemen
Burkina Faso
Estonia
Kenya
Moldova-Rep.
Qatar
Tanzania-UR
Zambia
Burundi
Ethiopia
Kiribati
Mongolia
Romania
Thailand
Zimbabwe
Cambodia
Fiji
Korea-DPR
Morocco
Russian Federation
Timor-Leste
Cameroon
French Polynesia
Korea-Republic
Mozambique
Rwanda
Togo
Source: World Health Organization Global Tuberculosis Control, WHO Report 2013, Countries with Tuberculosis incidence rates of > 20 cases per 100,000
population. For future updates, refer to http://www.who.int/topics/tuberculosis/en/.
Have you ever had an abnormal chest x-ray suggestive of TB?
Yes
No
No Response
Yes
No
No Response
Are you HIV positive?
Yes
No
No Response
Are you an organ transplant recipient or donor?
Yes
No
No Response
Are you immunosuppressed (taking an equivalent of > 15 mg/day of prednisone for >1 month, or
currently taking prescription arthritis medication)?
Are you a resident, employee, or volunteer in a high-risk congregate setting (e.g., correctional
Yes
No
No Response
facilities, nursing homes, homeless shelters, hospitals, and other health care facilities)?
Do you have any medical conditions such as diabetes, silicosis, head, neck, or lung cancer,
Yes
No
No Response
hematologic or reticuloendothelial disease such as Hodgkin’s disease or leukemia, end stage
renal disease, intestinal bypass or gastrectomy, chronic malabsorption syndrome, low body
weight (i.e., 10% or more below ideal)?
Do you have a cough lasting 3 weeks or longer, chest pain, weakness or fatigue, weight loss,
Yes
No
No Response
chills, fever and/or night sweats?
Yes
No
No Response
Are you coughing up blood or phlegm?
I hereby certify that this application contains no misrepresentation or falsification and that the information given by me is true and complete to the
best of my knowledge and belief.
______________________________________
_____________________________________
Patient Signature
Date:
(Required)
MO 580-3015 (03-14)
Missouri Department of Health and Senior Services
Bureau of Communicable Disease Control and Prevention
Tuberculosis (TB) Risk Assessment Form
C. Medical Evaluation (
)
Section C to be completed by Health Care Provider – if needed
Health Care Provider: If the answer to any of the TB Risk Assessment questions in Section B is YES or NO RESPONSE,
proceed with additional medical evaluation as appropriate. Additional evaluation may include one or more of the following:
TST, IGRA, sign and symptom review, chest x-ray, or sputum collection. If the patient is immunosuppressed and no
previous TB test is documented, an IGRA is recommended.
1.
Tuberculin Skin Test (TST) - Please provide a 2-step TST for those at high risk that have no documentation of a previous
TST: Administer 1st step TST today and read in 48-72 hrs, if the 1st step TST is positive, document the results in
millimeters (mm)of induration and follow the evaluation steps for a positive TST. If the 1st step TST is negative document the
results in mm of induration. Results of mm of induration, transverse diameter; if no induration write “0” mm. The TST
interpretation* should be based on mm of induration as well as risk factors. Place a 2-step TST in one to three weeks after the
first TST was read and recorded. The 2-step should be read in 48-72 hrs and then follow the documentation procedures as
outlined above .
Date Given: ____________
Date Read: ____________
Result: ________ mm of Induration
*Interpretation: Positive____ Negative____
Date Given: ____________
Date Read: ____________
Result: ________ mm of Induration
*Interpretation: Positive____ Negative____
*TST Interpretation Guidelines (Please check all that apply).
>5 mm is Positive:
Recent close contacts of an individual with
> 10 mm is:
Persons born in a high prevalence country or who resided in one for
infectious TB
Positive:
a significant amount of time
Persons with fibrotic changes on a prior chest x-ray
History of illicit drug use
consistent with past TB disease
Mycobacteriology laboratory personnel
Organ transplant recipients
History of resident, worker or volunteer in high-risk congregate settings
Immunosuppressed persons: taking > 15 mg/d of
Persons with the following clinical conditions: silicosis, diabetes
prednisone for > 1 month; taking a TNF-α
mellitus, chronic renal failure, leukemias and lymphomas, head, neck or
antagonist
lung cancer, low body weight (>10% below ideal), gastrectomy or
intestinal bypass, chronic malabsorption syndromes
Persons with HIV/AIDS
Children < 4 years of age
>15 mm is Positive:
Persons with no known risk factors for TB disease
Children and adolescents exposed to adults in high-risk categories
2.
Interferon Gamma Release Assay (
)
Please check the IGRA that is used
QFT-G
QFT-GIT
Date Obtained: _____________
Result:
Responsive
Nonresponsive
Indeterminate
(TB Infection Likely)
(TB Infection Unlikely)
T- Spot
Date Obtained: ____________
Result:
Negative
Positive
Borderline/Equivocal
Other: __________
Date Obtained: ____________
Result:________________________________
3.
Chest X-ray: (Required if TST or IGRA is positive)
Date of Chest X-ray: _________ Result:
Normal
Abnormal
Abnormal Chest X-ray Interpretation: ______________
Sputum Collection: If the patient has a positive TST or IGRA and a productive cough > 3weeks, with or without
4.
hemoptysis, please collect three (3) consecutive sputum, one early morning and all must be at least eight (8) hours apart with a
minimum of 2 milliliters of specimen per tube.
1. Date Obtained
Smear Result:
Culture Result:
2. Date Obtained:
Smear Result:
Culture Result:
__________________
______________
_____________
______________
_____________
______________
3. Date Obtained:
Smear Result:
Culture Result:
__________________
______________
______________
An isolate on any positive mycobacterium cultures should be sent to the Missouri State Public Health Laboratory.
I have reviewed the above information with the patient and deemed:
No Further Evaluation Needed
Further Evaluation is Needed
_________________________________________
_____________________________________
Health Care Provider Signature
Date:
(Required)
All positive TST, IGRA, chest x-ray, smear and culture results suggestive of tuberculosis disease or latent tuberculosis infection should be reported to the Missouri
Department of Health and Senior Services (fax number: 573-526-0235) or your local public health agency using this form. If you have any questions, please contact
the Bureau of Communicable Disease Control and Prevention at 573-751-6113.
MO 580-3015 (03-14)
Page of 2