TB Questionnaire

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You have indicated that you have had a positive TB test in the past. All positive TB reactors are required to complete the TB Questionnaire regarding the signs and symptoms of tuberculosis, on an annual basis.

Please read and place a checkmark in the correct YES/NO space if you are experiencing any of the following symptoms or if any of the following apply to you.
 YesNo
Unplanned weight loss (>10% of body weight)
Fever lasting several weeks
Coughing blood-streaked sputum
Pain in chest when taking a breath
Night sweats
Frequent coughing in absence of cold or flu
Have you recently been exposed to a family member or other person active with TB?
Have you recently been diagnosed with diabetes, silicosis, HIV, renal disease, or liver disease?
CONFIRMATION OF ENTRIES:

I understand that if I develop any of the symptoms listed above that I will be required to contact my physician as well as my Recruiter. I understand that a chest x-ray may be required prior to working again.

DECLINATION CONFIRMATION:

By signing where indicated below, I am agreeing with the above statements.

Professional's Signature:
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