Contractors / Security/ Volunteer / Student Health Initial Screening Questionnaire Form
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1Contractors / Security/ Volunteer / Student Health Initial Screening Questionnaire
PRINT FULL NAME:___________________________________SCHOOL: ______________________________
DEPT: _________________________ POSITION: __________________________
1.
___Yes ___No
Have you used another name? If yes, other name is ____________________________________________
2.
___Yes ___No
Have you volunteered or worked at any Kaiser? If so, where? _________________________________
3.
___Yes ___No
Do you have any allergies (e.g. drugs or latex)? If yes, describe__________________________________
4.
___Yes ___No
Have you been vaccinated for Hepatitis B? If so, when? _______________________________________
5.
___Yes ___No
If you have not received the Hepatitis B vaccine, would you like to be vaccinated?
6.
___Yes ___No
Have you had unexplained weight loss in the past year? If yes, amount lost is __________lbs.
7.
___Yes ___No
Do you have a persistent cough that has lasted more than 3 weeks?
8.
___Yes ___No
Do you cough up blood?
9.
___Yes ___No
Do you have persistent, unexplained fevers or night sweats?
10.
___Yes ___No
Do you have a rash? If yes, for how long? _________________________________________________
11.
___Yes ___No
Do you have a condition which is currently infectious? If yes, describe: _________________________
12.
___Yes ___No
Have you seen a doctor for any of the above? If yes, which numbered item? Any time that you
experience any symptom described in #7 - 11 above, you must see a provider immediately.
13.
___Yes ___No
Do you have a positive PPD? If so, when did it become positive? ______________________________
IF YOU ANSWERED “YES” TO #13, PLEASE ALSO ANSWER QUESTIONS 14 - 16.
Persons with a previous reaction to the TB skin test (Positive” PPDs) may have an increased risk of developing tuberculosis
disease if certain medical conditions exist, such as:
a.
Had part of your stomach removed by surgery.
e.
Diabetes
b.
Underweight or are malnourished.
f.
Silicosis lung disease
c.
Infection with HIV/Aids or are at risk for it
g.
Leukemia or lymphoma
d.
Medication that suppresses the immune system
h.
Kidney failure
14.
___Yes ___No
Do you have any of the above conditions (a-h)? You are not required to divulge your diagnosis.
15.
___Yes ___No
Did you ever take INH medication for your positive PPD? If so when? __________________________
16.
___Yes ___No
Have you ever had tuberculosis?
IF YOU ANSWERED “NO” TO #13, PLEASE ANSWER QUESTIONS 17-18 AND HAVE A PPD PLACED NOW.
Persons with damaged immune systems may not respond to PPD testing. You are at a higher risk for acquiring TB if your immune
system has been damaged by:
a.
Chemotherapy, steroid medications, or medications to prevent transplant rejection.
b.
Diseases such as HIV/AIDS, cancer and sarcoidosis.
c.
Any other condition that may suppress your immune system.
17.
___Yes ___No
Please indicate whether immune system may have been damaged by a condition above (a.b.c.).
18.
What was the date of your last TB skin test? ____________________________________________________________
19.
What was the date of the TB skin test prior to the current one? ______________________________________________
_____________________________
_______________
___________________________
__________________
Applicant Signature
Date
Reviewed by Employee Health/Designee
Date
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