Volunteer TB Screening Name * First Name Last Name Date of (+) TB Skin Test (PPD if applicable) Please indicate if you have had any of the following problems for three to four weeks or longer Chronic cough (greater than three weeks) Yes No Production of Sputum Yes No Blood Streaked Sputum Yes No Unexplained Weight Loss Yes No Fever Yes No Fatigue/Tiredness Yes No Night Sweats Yes No Shortness of Breath Yes No Been in close proximity to someone with active TB Yes No Lived in a congregate setting (> 1 month) Yes No By clicking YES you attest that the information I have given is true and accurate YES Electronic Signature Typing your name serves as a written signature Date MM DD YYYY Conclusion Thank you for completing the above information, you will be contacted if the DoPS determines further action is necessary. Director of Patient Services Signature Having reviewed the information given, further testing (Is/Is Not) required at this time. Is Is not Thank you!
