Tuberculosis Risk Assessment Form - Student Health Record - Becker College

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BECKER COLLEGE
Student Health Record
Name:________________________________________Student ID #______________________
GENERAL STUDY MAJORS: TUBERCULOSIS RISK ASSESSMENT:
(Tuberculosis is a contagious lung infection.)
1) Have you ever had a positive tuberculosis skin test? □ YES □NO x-ray required for (+)PPD
2) Have you had close contact with anyone who was sick with tuberculosis? □ *YES □ NO
3) Were you born in one of the countries listed below? □ *YES
□NO
4) Have you traveled or lived > one month in any of the countries listed below? □ *YES □NO
Physician Signature: _____________________________________________ Date: _______________
Physician Assessment (please check either low risk or high risk):
Low Risk
High Risk (Must complete PPD skin test as noted below).
If *YES response to 1 or more of questions 2-4; PPD skin test is required.
Afghanistan
Cambodia
Gabon
Lao PDR
Namibia
Rep. of Moldova
Togo
Algeria
Cameroon
Gambia
Latvia
Nauru
Romania
Turkmenistan
Angola
Cape Verde
Georgia
Lesotho
Nepal
Russian Federation
Tuvalu
Argentina
Central African Rep.
Ghana
Liberia
Nicaragua
Rwanda
Uganda
Armenia
Chad
Guam
Lithuania
Niger
Sao Tome & Principe
Ukraine
Azerbaijan
PR China
Guatemala
Madagascar
Nigeria
Saudi Arabia
UR Tanzania
Bangladesh
Colombia *
Guinea
Malawi
Niue
Senegal
Uzbekistan
Belarus
Comoros
Guinea-Bissau
Malaysia
Northern Mariana Island
Seychelles
Vanuatu
Belize
Côte d'Ivoire
Guyana
Maldives
Pakistan
Sierra Leone
Vietnam
Benin
Djibouti
Haiti
Mali
Palau
Solomon Islands
Wallis & Futuna
Bhutan
Dominican Republic
Honduras
Marshall Islands
Papua New Guinea
Somalia
Yemen
Bolivia
DPR Korea
India
Mauritania
Paraguay
South Africa
Zambia
Bosnia &
DR Congo
Indonesia
Mauritius
Peru
Sri Lanka
Zimbabwe
Herzegovina
Botswana
Ecuador
Iraq
Micronesia
Philippines
Sudan
Brazil
El Salvador
Kazakhstan
Mongolia
Qatar
Suriname
Brunei Darussalam
Equatorial Guinea
Kenya
Morocco
Rep. of Korea
Swaziland
Burkina Faso
Eritrea
Kiribati
Mozambique
Poland *
Tajikistan
Burundi
Ethiopia
Kyrgyzstan
Myanmar
Portugal *
Thailand
± World Health Organization, Global Tuberculosis Control: Estimated burden of TB in 2005
Http://www.who.int/tb/publications/global_report/2007/xls/global.xls
ALL Health Science Majors require PPD skin testing:
Animal/Vet Science Students: 1baseline PPD skin test. Nursing Students: 2-step PPD skin testing.
st
nd
1
Baseline PPD: All Health Science
2
PPD test (Nursing Students ONLY)
Plant Date: ____/____/____
Plant Date: ____/____/____
Read Date:___/___/___
Read Date:___/___/___
Result_______mm induration (0 if none)
Result_______mm induration (0 if none)
Signature:__________________________
Signature:_________________________
If Tuberculin Skin Test is POSITIVE, the following is required:
1) Date of Positive PPD: _______/________/______
2) Negative Chest X-Ray* (within 5 years of entry): Date:_____/_____/____ *Attach copy of x-ray
3) Treatment: □ YES □ NO If YES; treatment & dates____________________________________
Physician's Signature_______________________________
Date: __________________
BECKER COLLEGE
Student Health Record
Name:________________________________________Student ID #______________________
GENERAL STUDY MAJORS: TUBERCULOSIS RISK ASSESSMENT:
(Tuberculosis is a contagious lung infection.)
1) Have you ever had a positive tuberculosis skin test? □ YES □NO x-ray required for (+)PPD
2) Have you had close contact with anyone who was sick with tuberculosis? □ *YES □ NO
3) Were you born in one of the countries listed below? □ *YES
□NO
4) Have you traveled or lived > one month in any of the countries listed below? □ *YES □NO
Physician Signature: _____________________________________________ Date: _______________
Physician Assessment (please check either low risk or high risk):
Low Risk
High Risk (Must complete PPD skin test as noted below).
If *YES response to 1 or more of questions 2-4; PPD skin test is required.
Afghanistan
Cambodia
Gabon
Lao PDR
Namibia
Rep. of Moldova
Togo
Algeria
Cameroon
Gambia
Latvia
Nauru
Romania
Turkmenistan
Angola
Cape Verde
Georgia
Lesotho
Nepal
Russian Federation
Tuvalu
Argentina
Central African Rep.
Ghana
Liberia
Nicaragua
Rwanda
Uganda
Armenia
Chad
Guam
Lithuania
Niger
Sao Tome & Principe
Ukraine
Azerbaijan
PR China
Guatemala
Madagascar
Nigeria
Saudi Arabia
UR Tanzania
Bangladesh
Colombia *
Guinea
Malawi
Niue
Senegal
Uzbekistan
Belarus
Comoros
Guinea-Bissau
Malaysia
Northern Mariana Island
Seychelles
Vanuatu
Belize
Côte d'Ivoire
Guyana
Maldives
Pakistan
Sierra Leone
Vietnam
Benin
Djibouti
Haiti
Mali
Palau
Solomon Islands
Wallis & Futuna
Bhutan
Dominican Republic
Honduras
Marshall Islands
Papua New Guinea
Somalia
Yemen
Bolivia
DPR Korea
India
Mauritania
Paraguay
South Africa
Zambia
Bosnia &
DR Congo
Indonesia
Mauritius
Peru
Sri Lanka
Zimbabwe
Herzegovina
Botswana
Ecuador
Iraq
Micronesia
Philippines
Sudan
Brazil
El Salvador
Kazakhstan
Mongolia
Qatar
Suriname
Brunei Darussalam
Equatorial Guinea
Kenya
Morocco
Rep. of Korea
Swaziland
Burkina Faso
Eritrea
Kiribati
Mozambique
Poland *
Tajikistan
Burundi
Ethiopia
Kyrgyzstan
Myanmar
Portugal *
Thailand
± World Health Organization, Global Tuberculosis Control: Estimated burden of TB in 2005
Http://www.who.int/tb/publications/global_report/2007/xls/global.xls
ALL Health Science Majors require PPD skin testing:
Animal/Vet Science Students: 1baseline PPD skin test. Nursing Students: 2-step PPD skin testing.
st
nd
1
Baseline PPD: All Health Science
2
PPD test (Nursing Students ONLY)
Plant Date: ____/____/____
Plant Date: ____/____/____
Read Date:___/___/___
Read Date:___/___/___
Result_______mm induration (0 if none)
Result_______mm induration (0 if none)
Signature:__________________________
Signature:_________________________
If Tuberculin Skin Test is POSITIVE, the following is required:
1) Date of Positive PPD: _______/________/______
2) Negative Chest X-Ray* (within 5 years of entry): Date:_____/_____/____ *Attach copy of x-ray
3) Treatment: □ YES □ NO If YES; treatment & dates____________________________________
Physician's Signature_______________________________
Date: __________________
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Updated June 2012

Download Tuberculosis Risk Assessment Form - Student Health Record - Becker College

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