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 travel Current 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 explain Close contact with someone who has had TB disease Yes No Please explain Treatment for latent TB infection Yes No Please explain Prior diagnosis of active TB or latent TB infection or a positive skin test or positive blood test for TB Yes No Please explain Treatment with medication for TB or for a positive TB test Yes No Please explain Productive cough for more than 3 weeks Yes No Please explain Coughing up blood Yes No Please explain Unexplained Weight Loss Yes No Please explain Fever, chills, or drenching night sweats for no known reason Yes No Please explain Persistent shortness of breath Yes No Please explain Unexplained fatigue for more than 3 weeks Yes No Please explain Chest pain Yes No Please explain Employee Signature Date MM slash DD slash YYYY