Tb Risk Assessment Form
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1TB Risk Assessment Form
L Number/SSN____________________________________
Complete Sections A and B, or section C. Please write your name and sign the form at the bottom.
A. (circle Yes or No)
Yes No Have you ever been diagnosed with tuberculosis?
Yes No Have you ever had a positive PPD skin test or positive Interferon Gamma Release Assay blood (IGRA)
test?
►If you answered “Yes” to either question, you will need to present a report from your health care provider
about your chest x-ray, taken in the past 6 months in the USA.
►You must also provide a copy of your treatment, including medications and dates.
B. TB Exposure Risk Factors (circle Yes or No)
Yes No Foreign-born? Name of country of birth__________________________
Yes No Have you volunteered or lived in any of these settings in the past year?
__Hospital __Prison/jail __Long-term Care __Homeless Shelter __Alcohol and Drug Treatment Center
Yes No Have you been in close contact with someone who has active TB?
Yes No As a child, were you around an adult who had TB?
Yes No Have you ever been an injection drug user?
Yes No Have you traveled or lived in a high-risk country*? List countries to which you have
traveled.______________________________________________________________________________________________________
*Excludes Canada, Western Europe, Australia, New Zealand, and Japan
(circle Yes or No to any which apply)
Other medical conditions known to increase the risk of TB disease:
Yes No Diabetes
Yes No Silicosis
Yes No Leukemia, lymphoma
Yes No Cancer of the neck, head or lung
Yes No Immunosuppressive condition or therapy greater than 3 weeks (steroids or chemotherapy)
Yes No End-stage kidney disease
Yes No Intestinal bypass or gastrectomy
Yes No Chronic malabsorption syndrome (Crohn’s or Ulcerative Colitis)
Yes No Weight loss greater than 10% of your ideal body weight
Yes No HIV/AIDS
Yes No Autoimmune disease
Do you have any unexplained: (check if yes)
___ Cough ___Fever/chills ___Loss of appetite ___Weight loss ___Fatigue ___Night sweats
►If you answer “yes” to any question in section B, you must have proof of a TB screening test from the last year.
Acceptable tests include a PPD skin test or IGRA blood test. If either is positive, you must follow the directions
highlighted in section A. If all answers are “no,” you may skip section C and sign the bottom of the form to meet
the requirement.
C. TB screening test (PPD OR IGRA) (must be within 12 months prior to enrollment)
Date given____________ Given by _________(initials) Test reading location ________________________________________
PPD: Date read_____________ Results __________mm of induration Read by: ______________________________________
IGRA: ___positive ___negative ___intermediate
Actions taken:_________________________________________________________________________________________________
I, __________________________________ affirm that the information in Section A and B is accurate and truthful.
Print Name
Signature_________________________________ Date_______________
Health Center, Lipscomb University, One University Park Drive, Nashville, TN 37204
Toll Free: 800-333-4358, ext. 6304 Phone: 615.966.6304 Fax: 615.966.5286
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