"Tuberculosis Risk Assessment Form - Stafford County Public Schools Health Services"

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STAFFORD COUNTY PUBLIC SCHOOLS HEALTH SERVICES
Screening Created by PD 16 School Health TEAM
TUBERCULOSIS RISK ASSESSMENT FOR ALL NEW STUDENTS - CONFIDENTIAL
NAME:
GRADE/SCHOOL:
PARENT/GUARDIAN:
DATE:
The United States Public Health Service and the Centers for Disease Control and Prevention (CDC) recommend that tuberculosis
(TB) testing be performed on all individuals who may be at increased risk of TB. Please complete the following form.
1.
Was the student born in a country outside of the United States?
____ No
____ Yes
If yes, what country? ________________________________________
2.
Has the student spent three or more consecutive months in a foreign country in the last five years?
____ No
____ Yes
If yes, what country? ________________________________________
3.
Has the student been exposed to or had contact with a person with active TB in the last year?
____ No
____ Yes
If yes, who? ______________________________________________
4.
Was the student homeless/incarcerated or did he/she live in a shelter during the last two years?
____ No
____ Yes
5.
Does the student have any of the following: persistent cough, coughed up blood, fever for more than one week,
unexplained weight loss or HIV infection?
_____ No
____ Yes
If yes, please explain: ________________________________________
6.
Is the student currently taking oral steroid medication (other than inhalers), cancer treating drugs or any other medication
that might weaken his/her immune system?
____ No
____ Yes
If yes, please explain: ________________________________________
7.
Has the student ever had a positive test for TB or been treated for active TB disease or latent TB infection?
____ No
____ Yes
If yes, please provide details: __________________________________
__________________________________________________________
__________________________________________________________
8.
Does the student have any of the following medical conditions?
a.
Diabetes
No
Yes
f. Gastrectomy
No
Yes
b.
Malnutrition
No
Yes
g. Silicosis
No
Yes
c.
Cancer
No
Yes
d.
Chronic renal failure
No
Yes
e.
Congenital or acquired
Immunodeficiency
No
Yes
INSTRUCTIONS FOR HEALTHCARE PROVIDER: Please complete the following when the risk assessment
contains one or more positive (yes) answers. Return to the school nurse.
Date of TB test: ______________
-Type of TB Test: TB skin test OR IGRA (interferon gamma release assay)
Test result: ______ mm induration (for TST)
OR
IGRA result:
Positive
Negative
Indeterminate
CXR ordered? No____ Yes____
-If yes, result: ___________________________________________________
Treatment provided? No____ Yes____
-If yes, what? ______________________________________________
Name of Health Care Provider (please print): _________________________________________________________
Address: ______________________________________________________________________________________
Telephone: ____________________________________________________________________________________
Signature: ______________________________________________________________________
Revised March 2015
STAFFORD COUNTY PUBLIC SCHOOLS HEALTH SERVICES
Screening Created by PD 16 School Health TEAM
TUBERCULOSIS RISK ASSESSMENT FOR ALL NEW STUDENTS - CONFIDENTIAL
NAME:
GRADE/SCHOOL:
PARENT/GUARDIAN:
DATE:
The United States Public Health Service and the Centers for Disease Control and Prevention (CDC) recommend that tuberculosis
(TB) testing be performed on all individuals who may be at increased risk of TB. Please complete the following form.
1.
Was the student born in a country outside of the United States?
____ No
____ Yes
If yes, what country? ________________________________________
2.
Has the student spent three or more consecutive months in a foreign country in the last five years?
____ No
____ Yes
If yes, what country? ________________________________________
3.
Has the student been exposed to or had contact with a person with active TB in the last year?
____ No
____ Yes
If yes, who? ______________________________________________
4.
Was the student homeless/incarcerated or did he/she live in a shelter during the last two years?
____ No
____ Yes
5.
Does the student have any of the following: persistent cough, coughed up blood, fever for more than one week,
unexplained weight loss or HIV infection?
_____ No
____ Yes
If yes, please explain: ________________________________________
6.
Is the student currently taking oral steroid medication (other than inhalers), cancer treating drugs or any other medication
that might weaken his/her immune system?
____ No
____ Yes
If yes, please explain: ________________________________________
7.
Has the student ever had a positive test for TB or been treated for active TB disease or latent TB infection?
____ No
____ Yes
If yes, please provide details: __________________________________
__________________________________________________________
__________________________________________________________
8.
Does the student have any of the following medical conditions?
a.
Diabetes
No
Yes
f. Gastrectomy
No
Yes
b.
Malnutrition
No
Yes
g. Silicosis
No
Yes
c.
Cancer
No
Yes
d.
Chronic renal failure
No
Yes
e.
Congenital or acquired
Immunodeficiency
No
Yes
INSTRUCTIONS FOR HEALTHCARE PROVIDER: Please complete the following when the risk assessment
contains one or more positive (yes) answers. Return to the school nurse.
Date of TB test: ______________
-Type of TB Test: TB skin test OR IGRA (interferon gamma release assay)
Test result: ______ mm induration (for TST)
OR
IGRA result:
Positive
Negative
Indeterminate
CXR ordered? No____ Yes____
-If yes, result: ___________________________________________________
Treatment provided? No____ Yes____
-If yes, what? ______________________________________________
Name of Health Care Provider (please print): _________________________________________________________
Address: ______________________________________________________________________________________
Telephone: ____________________________________________________________________________________
Signature: ______________________________________________________________________
Revised March 2015
SCHOOL BOARD POLICY FOR TUBERCULOSIS SCREENING REQUIREMENTS
I. Students entering school for the first time or returning after three months outside the United States must provide
documentation from a licensed physician, nurse practitioner, physician assistant or registered nurse prior to entry of a:
A. TB Risk Assessment documenting low risk for TB disease. All answers on the Risk Assessment should be
– OR –
negative. BCG vaccination does not exclude student from following protocol.
B. Documentation of a negative TB (Mantoux) skin test or interferon gamma release assay within the past 12 months
– OR –
or after exposure.
C. Written documentation of having successfully completed treatment for active tuberculosis disease.
II. Students shall be excluded from school until the TB policy requirement is met. As part of the risk assessment and
targeted screening process, questions arise concerning the definition “high prevalence country” for the purposes of
completing the risk assessment tool and determining who should receive a test for tuberculosis (either a tuberculin skin
test (TST) or interferon gamma release assay (IGRA).
III. Countries at low-risk for tuberculosis (defined as less than 20 TB cases per 100,000 population)
Current Exception List – March 2015
(case rates from WHO 2014 Global Report)
Test for Latent TB Infection Only if Symptomatic or an Additional Individual Risk Factor is Present
African Region
American Region
Eastern
European
Western Pacific
Southeast Asia
Mediterranean
Region
Region
Region
Albania
Egypt
Antigua & Barbuda
Bahrain
American Samoa
No exception
Andorra
Antilles
Israel
Australia
countries
Austria
Aruba
Jordan
Cook Islands
Belgium
Bahamas
Lebanon
Japan
Croatia
Barbados
Oman
New Caledonia
Cyprus
Bonaire, Saint
Saudi Arabia
New Zealand
Czech Republic
Eustatius and Saba
Syrian Arab
Niue
Denmark
Canada
Republic
Samoa
Finland
Caymen Islands
United Arab
Tokelau
Former Yugoslav
Chile
Emirates
Tonga
Republic of
Costa Rica
West Bank and
Macedonia
Wallis & Futuna
France
Cuba
Gaza Strip
Islands
Germany
Curacao
Greece
Dominica
Hungary
Grenada
Iceland
Jamaica
Ireland
Montserrat
Italy
Puerto Rico
Luxembourg
Saint Kitts & Nevis
Malta
Saint Lucia
Monaco
Sint Maarten
Netherlands
Norway
(Dutch
San Marino
Part)
Serbia
Turks & Caicos
Slovakia
United States
Spain
Virgin Islands (US
Sweden
& BR)
Switzerland
Turkey
United Kingdom
Revised March 2015
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