Please enable JavaScript in your browser to complete this form.First Name *Last Name *Date *Email *Phone *As required by the US Department of Health, all volunteers and staff working with populations with compromised immune systems must answer the following questions to determine their risk for being carriers of Tuberculosis. Please check “yes” for any of the statements that are true for you; check “no” for any that are not true. “Close contact” means: sharing the same residence or spent long periods of time together (for example, 4 or more hours at a time.1. I have been in close contact with someone who has confirmed or suspected contagious tuberculosis since the last time I had a TB screening test. *YesNoI have a question2. I have had a persistent cough or fever over the past three weeks. *YesNoI have a question3. I have had unintentional weight loss over the past 2 months. *YesNoI have a question4. I have been in close contact with immigrants from* Asia, The Middle East, Africa, Latin America or Eastern Europe including international adoptees since my last TB screening test. *YesNoI have a question*Afghanistan, Bangladesh, Brazil, Cambodia, China, Congo, (Dem Republic of), Ethiopia, India, Indonesia, Kenya, Mozambique, Myanmar, Nigeria, Pakistan, Philippines, Russian Federation, South Africa, Tanzania (United Rep. of), Thailand, Uganda, Vietnam, Zimbabwe5. I have traveled for a month or more to any of the regions listed in number 3 and have not had a TB screening test since returning. *YesNoI have a question6. I am from any of the regions listed in number 3 and have not had a TB screening test since immigrating. (Please provide documentation of last Tb screening test.) *YesNoI have a question7. I have been incarcerated and have not had a TB screening test since incarceration. *YesNoI have a question8. I have been in close contact with migrant farm workers, nursing home residents, prison populations, or homeless shelters and have not had a TB screening test since this contact. *YesNoI have a question9. I am HIV infected or have been in close contact with HIV infected individuals and have not had a TB screening test in the past year. (Confidential) *Yes – please inform a REACH staff memberNoI have a questionIf you selected “Yes” for any of the above statements, or if Question #8 is true for you, you need to get a TB test. It is recommended that you visit with your Primary Care Provider to evaluate your symptoms and perform a full medical evaluation. Please mail those results to REACH: 309 South G Street, Suite 3, Tacoma, WA 98405, or email to: cbryan@REACHministries.org.Submit
