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Mark Twain Union ESD |  E  4112.4  Personnel

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ADULT TUBERCULOSIS (TB) RISK ASSESSMENT QUESTIONNAIRE

(To satisfy California Education Code Section 49406 and Health and Safety Code Sections 121525-121555)

To be administered by a licensed health care provider

(physician, physician assistant, nurse practitioner, registered nurse)

Date of Risk Assessment:

Name:_________________________________________ Date of Birth:________________

Best Contact Phone Number:_(____)_________________

History of positive TB test or TB disease: Yes No

If yes, a symptom review and chest x-ray (If none performed in previous 6 months) should be performed at initial hire or volunteer service.

If no, continue with questions below.

If there is a "Yes" response to any of the questions 1-5 below, then a tuberculin skin test (TST) or Interferon Gamma Release Assay (IGRA) should be performed. A positive test should be followed by a chest x-ray, and if normal, treatment for TB infection considered.

Risk Factors

1. One or more signs and symptoms of TB (prolonged cough, coughing up blood, fever, night sweats, weight loss, excessive fatigue)

__ Yes __ No

Note: A chest x-ray and/or sputum examination may be necessary to rule out infectious TB.

2. Close contact with someone with infectious TB disease

__ Yes __ No

3. Birth in high TB-prevalence country

(Any country other than the United States, Canada, Australia, New Zealand, or a country in Western or Northern Europe.)

__ Yes __ No

4. Travel to high TB-prevalence country for more than one month

(Any country other than the United States, Canada, Australia, New Zealand, or a country in Western or Northern Europe.)

__ Yes __ No

5. Current or former residence or work in a correctional facility, long-term care facility, hospital, or homeless shelter.

__ Yes __ No

*Once a person has a documented positive test for TB infection that has been followed by an x-ray that was deemed free of infectious TB, the TB risk assessment is no longer required.

Exhibit MARK TWAIN UNION ELEMENTARY SCHOOL DISTRICT

version: April 09, 2015 Angels Camp, California

___________________________________________________________________________

Exhibit (2)

ADULT TUBERCULOSIS (TB) RISK ASSESSMENT QUESTIONNAIRE

(To satisfy California Education Code Section 49406 and Health and Safety Code Sections 121525-121555)

CERTIFICATE OF COMPLETION

To be signed by the licensed health care provider completing the risk assessment and/or examination

Date of Risk Assessment:

Name:_________________________________________ Date of Birth:________________

The above named patient has submitted to a tuberculosis risk assessment.

__ The above named patient does not have tuberculosis risk factors.

__ The above named patient was identified to have tuberculosis risk factors.

__ The above named patient has been examined and determined to be free of infectious Tuberculosis.

___________________________________________________________________________

Health Care Provider Signature

___________________________________________________________________________

Please Print Health Care Provider Title

___________________________________________________________________________

Office Address: Street City State Zip

___________________________________________________________________________

Telephone Fax

Exhibit MARK TWAIN UNION ELEMENTARY SCHOOL DISTRICT

version: April 09, 2015 Angels Camp, California