TB Screening Form

Infiniti Home Health Care, LLC

TB Screening

* = Required Information

Employee *

Do you currently have any of the following that has lasted three (3) weeks or longer?

1. Unexplained productive cough?

Yes

2. Unexplained weight loss?

Yes

3. Unexplained appetite loss?

Yes

4. Unexplained fever?

Yes

5. Night sweats?

Yes

6. Shortness of breath?

Yes

7. Chest pain?

Yes

8. Increased fatigue?

Yes

9. Bloody sputum?

Yes

Have you ever:

A. Ever been told you have TB?

Yes

B. Lived with anyone with TB?

Yes

C. Had a positive TB skin test?

Yes

D. Had a BCG vaccination?

Yes

E. Date of last negative PPD skin test result:

Employee Signature *

Clear

Date *

EMPLOYER REVIEW:
I) If the employee answers yes to any question 1-9, document the objective reason for the symptom. If there is no known reason for the symptom lasting 3 weeks or longer, the employee is to have a TB skin test.
II) If the employee answers yes to any question A-B, the employee is to have a TB skin test.
III) If the employee answers yes to question C, the employee is to have either a chest x-ray or a physician statement noting the employee is free from communicable disease.

The following apply to this employee:

III

None

Administrative Review:

Completed by:

Date