Verification Of Student Admission Information (For Student Residing With Parent Or Guardian)/proof Of Residency Form (Page 13 of 13) in pdf

TB Questionnaire

Name of Child____________________________________________________________Date of Birth ________________

Organization administering questionnaire______________________________________ Date_______________________

Tuberculosis (TB) is a disease caused by TB germs and is usually transmitted by an adult person with active TB lung

disease. It is spread to another person by coughing or sneezing TB germs into the air. These germs may be breathed in by

the child.

Adults who have active TB disease usually have many of the following symptoms: cough for more that two weeks duration,

loss of appetite, weight loss of ten or more pounds over a short period of time, fever, chills and night sweats.

A person can have TB germs in his or her body but not have active TB disease (this is called latent TB infection or LTBI).

Tuberculosis is preventable and treatable. TB skin testing (often called the PPD or Mantoux test) is used to see if your

child has been infected with TB germs. No vaccine is recommended for use in the United States to prevent tuberculosis.

The skin test is not a vaccination against TB.

We need your help to find out if your child has been exposed to tuberculosis.

Place a mark in the appropriate box:

Yes

Don't

Know

TB can cause fever of long duration, unexplained weight loss, a bad cough (lasting over two

weeks), or coughing up blood. As far as you know:

has your child been around anyone with any of these symptoms or problems? or

has your child had any of these symptoms or problems? or

has your child been around anyone sick with TB?

Was your child born in Mexico or any other country in Latin America, the Caribbean, Africa,

Eastern Europe or Asia?

Has your child traveled in the past year to Mexico or any other country in Latin America, the

Caribbean, Africa, Eastern Europe or Asia for longer than 3 weeks?

If so, specify which country/countries?______________________________________

To your knowledge, has your child spent time (longer than 3 weeks) with anyone who is/has

been an intravenous (IV) drug user, HIV-infected, in jail or prison or recently came to the

United States from another country?

Has your child been tested for TB?

Yes___ (if yes, specify date ____/____)

No___

Has your child ever had a positive TB skin test?

Yes___ (if yes, specify date ____/____)

No___

For school/healthcare provider use only

***************************************************************************************************

PPD administered

Yes___

No___

If yes,

Date administered _____/_____/______ Date read ______/______/_______ Result of PPD test __________ mm response

Type of service provider (i.e. school, Health Steps, other clinics) _______________________________________________

PPD provider

__________________________________________

______________________________________

signature

printed name

Provider phone number

___________________________________

City ________________________________________________ County ________________________________________

If positive, referral to healthcare provider

Yes___

No___

If yes, name of provider _______________________________________________________________________________

EF12-11494 TB Questionnaire for Children (Rev. 08/04)

Verification Of Student Admission Information (For Student Residing With Parent Or Guardian)/proof Of Residency Form Page 13

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