Form TB-8 Attachment 1 "Symptom Assessment for Pulmonary Tuberculosis (Tb) Religious Exemption - School Tb Testing" - New Jersey

What Is Form TB-8 Attachment 1?

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

Form Details:

  • Released on August 1, 2012;
  • The latest edition provided by the New Jersey Department of Health;
  • 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 TB-8 Attachment 1 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Health.

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Download Form TB-8 Attachment 1 "Symptom Assessment for Pulmonary Tuberculosis (Tb) Religious Exemption - School Tb Testing" - New Jersey

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Attachment 1
New Jersey Department of Health
Symptom Assessment for Pulmonary Tuberculosis (TB)
Religious Exemption – School TB Testing
Name (Last, First, MI)
Birthdate (mm/dd/yyyy)
Street Address
Telephone Number
City
State
Zip Code
Date of Symptom Assessment (mm/dd/yyyy)
TB-Like Symptoms (Check all that apply):
Productive Cough of Undiagnosed Cause (more than 3 weeks in duration)
Coughing Up Blood (Hemoptysis)
Unexplained Weight Loss (10 pounds or greater without dieting)
Night Sweats (regardless of room temperature)
Unexplained Loss of Appetite
Very Easily Tired (Fatigability)
Fever
Chills
Chest Pain
If any symptoms are reported a chest radiograph is an essential criterion for school
admission.
No TB-Like Symptoms Reported or Observed
Name of Licensed MD/RN (Print)
Signature of Licensed MD/RN
Date
TB-8
AUG 12
Attachment 1
New Jersey Department of Health
Symptom Assessment for Pulmonary Tuberculosis (TB)
Religious Exemption – School TB Testing
Name (Last, First, MI)
Birthdate (mm/dd/yyyy)
Street Address
Telephone Number
City
State
Zip Code
Date of Symptom Assessment (mm/dd/yyyy)
TB-Like Symptoms (Check all that apply):
Productive Cough of Undiagnosed Cause (more than 3 weeks in duration)
Coughing Up Blood (Hemoptysis)
Unexplained Weight Loss (10 pounds or greater without dieting)
Night Sweats (regardless of room temperature)
Unexplained Loss of Appetite
Very Easily Tired (Fatigability)
Fever
Chills
Chest Pain
If any symptoms are reported a chest radiograph is an essential criterion for school
admission.
No TB-Like Symptoms Reported or Observed
Name of Licensed MD/RN (Print)
Signature of Licensed MD/RN
Date
TB-8
AUG 12