Tuberculosis Risk Assessment Tuberculosis Risk Assessment Name First DOB Month Day Year Email Last 4 of SS#Have you traveled out of the country recently and remained there for more than 1 month? Yes No Please specify country of travelCurrent or planned immunosuppression, including HIV infection, receipt of an organ transplant, treatment with an TNF-alpha antagonist (e.g., infliximab, etanercept, or other), chronic steroids (equivalent of prednisone 15 mg/day for 1 month) or other immunosuppressive medication Yes No Please explainClose contact with someone who has had TB disease Yes No Please explainTreatment for latent TB infection Yes No Please explainPrior diagnosis of active TB or latent TB infection or a positive skin test or positive blood test for TB Yes No Please explainTreatment with medication for TB or for a positive TB test Yes No Please explainProductive cough for more than 3 weeks Yes No Please explainCoughing up blood Yes No Please explainUnexplained Weight Loss Yes No Please explainFever, chills, or drenching night sweats for no known reason Yes No Please explainPersistent shortness of breath Yes No Please explainUnexplained fatigue for more than 3 weeks Yes No Please explainChest pain Yes No Please explainEmployee SignatureDate MM slash DD slash YYYY