First-Year Student Tuberculosis Screening Form
Student Information
Full Name
Date of Birth
Student ID
Phone Number
Email Address
Screening Questions
Have you ever had a positive TB test?
Yes
No
If yes, specify date
Have you ever been treated for TB?
Yes
No
If yes, where and when?
Within the past 12 months, have you traveled or resided in a country with high rates of TB?
Yes
No
If yes, list countries
Have you had close contact with someone diagnosed with TB?
Yes
No
Do you have any of the following symptoms? (check all that apply)
Cough lasting more than 3 weeks
Unexplained weight loss
Fever
Night Sweats
None
Verification
Student Signature
Date