Form F-02314A "Wisconsin Tuberculosis (Tb) Risk Assessment and Symptom Evaluation for Wisconsin Public School Employees" - Wisconsin

What Is Form F-02314A?

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

Form Details:

  • Released on October 1, 2019;
  • The latest edition provided by the Wisconsin Department of Health 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 fillable version of Form F-02314A by clicking the link below or browse more documents and templates provided by the Wisconsin Department of Health Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form F-02314A "Wisconsin Tuberculosis (Tb) Risk Assessment and Symptom Evaluation for Wisconsin Public School Employees" - Wisconsin

Download PDF

Fill PDF online

Rate (4.8 / 5) 11 votes
Page background image
DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Public Health
Page 1 of 2
F-02314A (10/2019)
WISCONSIN TUBERCULOSIS (TB) RISK ASSESSMENT AND SYMPTOM EVALUATION
FOR WISCONSIN PUBLIC SCHOOL EMPLOYEES
All of the information on this form shall be kept confidential.
Perform testing by interferon gamma release assay (IGRA) or tuberculin skin test (TST) if there are TB risk factors
and/or symptoms identified by the questions below, or if testing is required (e.g., baseline employment testing).
Do not perform testing by IGRA or TST if the patient has previously confirmed latent tuberculosis infection (LTBI) or
tuberculosis (TB) disease.
Do not treat for LTBI until active TB disease has been excluded:
Evaluate for active TB disease with a chest x-ray, symptom evaluation, and if indicated, sputum AFB smears,
cultures and nucleic acid amplification testing. A negative TST or IGRA does not rule out active TB disease.
If any of the following boxes are checked, recommend LTBI testing.
See page 2 for more detailed information on the risk assessment questions below.
SYMPTOM EVALUATION
YES NO
Recent TB symptoms: Persistent cough lasting three or more weeks AND one or more of the following
symptoms: coughing up blood, fever, night sweats, unexplained weight loss, or fatigue
RISK FOR TB INFECTION
YES NO
Birth, residence or travel (for ≥ 1 month) in a country with a high TB rate
Includes any country other than the United States, Canada, Australia, New Zealand, or a country
in western or northern Europe.
Travel is of extended duration or including likely contact with infectious TB.
Close contact to someone with infectious TB disease
YES
NO
RISK FOR PROGRESSION TO TB DISEASE
YES NO
Human immunodeficiency virus (HIV) infection
YES NO
Current or planned immunosuppression including receipt of an organ transplant, treatment with an
TNF-alpha antagonist (e.g., infliximab, etanercept, or other), chronic steroids (equivalent of prednisone
≥15 mg/day for ≥1 month), or other immunosuppressive medication in combination with risk for
infection from above
A TB risk assessment and symptom evaluation have been completed for the individual named below. No risks or
symptoms for TB were identified.
A TB risk assessment and symptom evaluation have been completed for the individual named below. Risk factors
and/or symptoms for TB have been identified; further testing is recommended to determine the presence or absence
of tuberculosis in a communicable form.
Name Screener (Print):
Individual/Patient Name (Print):
Assessment Date:______________________________
Date of Birth: _______________________________
(Place sticker here if applicable.)
(Place sticker here if applicable.)
Clear/Reset Entire form
DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Public Health
Page 1 of 2
F-02314A (10/2019)
WISCONSIN TUBERCULOSIS (TB) RISK ASSESSMENT AND SYMPTOM EVALUATION
FOR WISCONSIN PUBLIC SCHOOL EMPLOYEES
All of the information on this form shall be kept confidential.
Perform testing by interferon gamma release assay (IGRA) or tuberculin skin test (TST) if there are TB risk factors
and/or symptoms identified by the questions below, or if testing is required (e.g., baseline employment testing).
Do not perform testing by IGRA or TST if the patient has previously confirmed latent tuberculosis infection (LTBI) or
tuberculosis (TB) disease.
Do not treat for LTBI until active TB disease has been excluded:
Evaluate for active TB disease with a chest x-ray, symptom evaluation, and if indicated, sputum AFB smears,
cultures and nucleic acid amplification testing. A negative TST or IGRA does not rule out active TB disease.
If any of the following boxes are checked, recommend LTBI testing.
See page 2 for more detailed information on the risk assessment questions below.
SYMPTOM EVALUATION
YES NO
Recent TB symptoms: Persistent cough lasting three or more weeks AND one or more of the following
symptoms: coughing up blood, fever, night sweats, unexplained weight loss, or fatigue
RISK FOR TB INFECTION
YES NO
Birth, residence or travel (for ≥ 1 month) in a country with a high TB rate
Includes any country other than the United States, Canada, Australia, New Zealand, or a country
in western or northern Europe.
Travel is of extended duration or including likely contact with infectious TB.
Close contact to someone with infectious TB disease
YES
NO
RISK FOR PROGRESSION TO TB DISEASE
YES NO
Human immunodeficiency virus (HIV) infection
YES NO
Current or planned immunosuppression including receipt of an organ transplant, treatment with an
TNF-alpha antagonist (e.g., infliximab, etanercept, or other), chronic steroids (equivalent of prednisone
≥15 mg/day for ≥1 month), or other immunosuppressive medication in combination with risk for
infection from above
A TB risk assessment and symptom evaluation have been completed for the individual named below. No risks or
symptoms for TB were identified.
A TB risk assessment and symptom evaluation have been completed for the individual named below. Risk factors
and/or symptoms for TB have been identified; further testing is recommended to determine the presence or absence
of tuberculosis in a communicable form.
Name Screener (Print):
Individual/Patient Name (Print):
Assessment Date:______________________________
Date of Birth: _______________________________
(Place sticker here if applicable.)
(Place sticker here if applicable.)
Clear/Reset Entire form
F-02314A (10/2019)
Page 2 of 2
Risk Assessment Details
USE OF THIS FORM
Use this form to assess individual risks for M. tuberculosis infection in adults (age ≥ 15 years).
SYMPTOM EVALUATION
TB symptoms are listed on the front of this form. TB can occur anywhere in the body but the most common areas
include; lungs, pleural space, lymph nodes and major organs such as heart, liver, spleen, kidney, eyes and skin. Clinical
judgement should be accompanied by careful evaluation of patient history including residence in a country with high TB
4
incidence, history of previous treatment for TB or LTBI and history of TB in the family.
RISK FOR TB INFECTION
Birth, travel or residence (for ≥ 1 month) in a country with a high TB rate
The World Health Organization (WHO) estimates TB incidence around the world in the Global Tuberculosis Report.
1, 5
Please see this report for countries with high TB rates, or call the Wisconsin Tuberculosis Program.
Leisure travel to most countries in the world poses little risk of TB infection. Prolonged stays or work in the health
2
sector in an endemic country increase the risk of infection.
Close Contact to someone with infectious TB disease
Infectious TB includes pulmonary, culture-positive disease and disease with pulmonary cavitation on radiograph.
High Priority contacts include household members (1 in 3 chance of infection), children < 5 years of age and
immunosuppressed individuals (HIV-positive, organ transplant, cancer, diabetes). Also consider those exposed for
3
shorter duration in a more confined space (exam room, dormitory room, office or vehicle).
Other Risks
Wisconsin has very low incidence of TB in healthcare, homeless, corrections and long-term care settings. Higher-risk
5
congregate settings occur in Alaska, California, Florida, Hawaii, New Jersey, New York, Texas or Washington DC.
Consult with local health departments for other locally identified high-risk groups:
https://www.dhs.wisconsin.gov/lh-
depts/counties.htm.
Consult with the Centers for Disease Control and Prevention (CDC) annual TB reports and the Wisconsin TB Program
6, 7, 8, 9
website for state and local epidemiology data.
RISK FOR PROGRESSION TO TB DISEASE
Immune suppression is a risk factor for reactivation and progression to active TB disease. Immune suppression alone is
not a risk for acquiring TB infection.
LTBI treatment should be strongly considered in HIV-infected individuals; significant immune suppression can
cause inaccuracy of diagnostic TB tests.
LTBI treatment can be considered for other immune suppression (e.g., cancer, organ transplant, medications, or
diabetes) when in combination with risk for infection (see above).
References:
1) World Health Organization Global Tuberculosis Report 2018.
https://www.who.int/tb/publications/global_report/en/
2) Cobelens, F.G.J., et al (2000). Risk of infection with Mycobacterium tuberculosis in travelers to areas of high tuberculosis
endemicity. The Lancet, 356, 461-465.
3) CDC. Guidelines for the investigation of contacts of persons with infectious tuberculosis: recommendations from the
National Tuberculosis Controllers Association and CDC. MMWR 2005; 54(No. RR-15).
4) Lewinsohn, D. et al. Official American Thoracic Society/Infectious Diseases Society of America/CDC Clinical Practice
Guidelines: Diagnosis of tuberculosis in adults and children. Clinical Infectious Diseases, 2017; 62(2):111-115.
5) Wisconsin Tuberculosis Program.
https://www.dhs.wisconsin.gov/tb/index.htm.
Phone: 608-261-6319.
6)
CDC. Reported Tuberculosis in the United States.
https://www.cdc.gov/tb/statistics/
7) CDC. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. MMWR
2005; 54(No. RR-17).
8) CDC. Tuberculosis screening, testing, and treatment of U.S. health care personnel: Recommendations from the National
Tuberculosis Controllers Association and CDC, 2019. MMWR 2019: 68(No. 19).
9) CDC. Prevention and control of tuberculosis in correctional facilities: Recommendations from CDC. MMWR 2006; 55(No.
RR-9).
Page of 2