Form TB-113 Tuberculosis Risk Assessment for Children - San Diego County, California

Form TB-113 or the "Tuberculosis Risk Assessment For Children" is a form issued by the California Department of Health Care Services.

The form was last revised in February 1, 2016 and is available for digital filing. Download an up-to-date Form TB-113 in PDF-format down below or look it up on the California Department of Health Care Services Forms website.

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Tuberculosis Risk Assessment for Children
The San Diego County Tuberculosis (TB) Control Branch has developed this document to assist providers in
performing TB risk assessment to prioritize children for TB screening.
Name of Child:
Medical Record #
DOB:
Date of Assessment:
Health Care Worker completing form:
Yes
No
1. Has a family member or anyone the child sees regularly been diagnosed or suspected of
being sick with active TB disease?
2. Does the child have family members or frequent visitors who were born in moderate or high
TB prevalence countries (most countries in Latin America –including Mexico, Asia, Africa,
and Eastern Europe)?
3. Was the child born in, or travel to, moderate or high TB prevalence countries?
4. Does the child live in Mexico or cross the border on a regular basis?
5. Does the child have HIV infection or another immunosuppressive condition?
6. Has the child lived among or frequently been around individuals who are homeless, have a
history of incarceration, or users of street drugs?
7. Has the child drank raw milk or eaten unpasteurized cheese?
Comments: ______________________________________________________________________________
Instructions to Health Care Worker:
Administer a TB test to children who have one or more of the above risk factors, unless the child has written
documentation of a positive TB test. Documentation should include the date of the positive test and the quantitative
result (e.g. IU, mm of induration). A positive test should be followed by a chest X-ray and examination to rule out
active TB disease. Once active TB is ruled out, treatment for latent TB infection is recommended unless the child has
been previously treated or has contraindications.
TB testing may be performed with either a currently approved interferon gamma release assay (IGRA) test or a TB
skin test. IGRAs are the preferred method for those children who have received BCG vaccination, which includes most
foreign-born individuals. TB skin tests are preferred for children under 3-5 years of age.
HHSA: TB-113 (2/16)
Tuberculosis Risk Assessment for Children
The San Diego County Tuberculosis (TB) Control Branch has developed this document to assist providers in
performing TB risk assessment to prioritize children for TB screening.
Name of Child:
Medical Record #
DOB:
Date of Assessment:
Health Care Worker completing form:
Yes
No
1. Has a family member or anyone the child sees regularly been diagnosed or suspected of
being sick with active TB disease?
2. Does the child have family members or frequent visitors who were born in moderate or high
TB prevalence countries (most countries in Latin America –including Mexico, Asia, Africa,
and Eastern Europe)?
3. Was the child born in, or travel to, moderate or high TB prevalence countries?
4. Does the child live in Mexico or cross the border on a regular basis?
5. Does the child have HIV infection or another immunosuppressive condition?
6. Has the child lived among or frequently been around individuals who are homeless, have a
history of incarceration, or users of street drugs?
7. Has the child drank raw milk or eaten unpasteurized cheese?
Comments: ______________________________________________________________________________
Instructions to Health Care Worker:
Administer a TB test to children who have one or more of the above risk factors, unless the child has written
documentation of a positive TB test. Documentation should include the date of the positive test and the quantitative
result (e.g. IU, mm of induration). A positive test should be followed by a chest X-ray and examination to rule out
active TB disease. Once active TB is ruled out, treatment for latent TB infection is recommended unless the child has
been previously treated or has contraindications.
TB testing may be performed with either a currently approved interferon gamma release assay (IGRA) test or a TB
skin test. IGRAs are the preferred method for those children who have received BCG vaccination, which includes most
foreign-born individuals. TB skin tests are preferred for children under 3-5 years of age.
HHSA: TB-113 (2/16)

Download Form TB-113 Tuberculosis Risk Assessment for Children - San Diego County, California

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