Child And Youth Tuberculosis Screening Certificate
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1CHILD AND YOUTH TUBERCULOSIS SCREENING CERTIFICATE
TO BE COMPLETED BY HEALTH CARE PROVIDER
(EL PROVEDOR MÉDICO DEBE COMPLETAR ESTE FORMULARIO)
NAME
_____________________________
DATE _____________________
1. Does child/youth have any of the following symptoms? (Check all that apply.)
____ Cough > 3 weeks
____ Unexplained fever
____Night sweats
____Unexplained weight loss
NO to all
Go to question #2
YES to any
Evaluate symptoms
2. Has the child/youth ever had a positive (+) Tuberculosis Skin Test (TST)?
NO
Go to question #3
YES
Confirm that child/youth was appropriately evaluated, i.e., had a documented negative x-ray and
treatment for latent TB infection was recommended.
3. Ask ALL the following risk assessment questions and check YES or NO.
YES
NO
a.
Was the child/youth born in a high risk country?* (If yes, plant only if no prior TST)
Since the child/youth’s last Risk Assessment or last negative TST:
YES
NO
b.
Has the child/youth traveled in (>1 week) a high-risk country?* (If yes, plant TST at least 10
weeks after return from travel.) TST will be due_______________________
YES
NO
c.
Has the child/youth lived in (>3 months) a high risk country?*
YES
NO
d.
Has a household member or close contact of the child/youth had tuberculosis disease?
YES
NO
e.
Has a household member or close contact of the child/youth had a positive TST?
YES
NO
f.
Has the child/youth been a resident of a shelter, prison, or jail?
YES
NO
g.
Has a close contact of the child/youth been a resident or employee of a shelter, prison, jail,
nursing home or assisted living facility?
CONTINUE ONLY IF CLIENT IS < 6 YEARS OF AGE:
YES
NO
h.
Was a parent/guardian of the child born in a high risk country?* (If yes, plant only if no prior TST)
YES
NO
i.
Has the child had household or close contact with people (e.g., a babysitter) from a high risk
country?*
If NO to 3a-i, sign certificate below.
If YES to any of questions 3a-i, plant TST and read at 48-72 hours
*High risk countries = Countries other than the US, Canada, Australia, New Zealand, or in Western Europe
CDC Classification of Positive TST Reaction
Tuberculin Skin Test (TST)
>
5mm: HIV+ persons, recent contacts of TB case,
Date planted: _______
Site: LFA / RFA
patients with organ transplant, other immunosuppressed patients
Planted by: ______________________
>
Date read: _______
Induration _______ mm
10mm: children 4 years or younger or anyone else with positive
Read by:
response to the risk questions above.
If desired, clip along dotted line and give portion below to parent for child’s school.
CERTIFICATE OF TB SCREENING
Name of child/youth:____________________________________ DOB: __________ School: ______________________
____ Risk factor identified, TST placed on ____________ TST results
Date TST read _____________
mm
____ Prior documented (+) TST, no TST planted
____ No risk factors identified, no TST needed
_________________________________
Date___________
Physician or RN signature
Physician’s stamp & address here:
Revised 07/21/2010
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