Revisión anual de los síntomas de la tuberculosis

"*" señala los campos obligatorios

Name*
Email*
Were you born in, or have you had temporary or permanent residence of > 1 month in a country with an elevated TB rate?*

Includes any country other than the United States, Canada, Australia, New Zealand, or a country in western or northern Europe.

Do you have current or planned immunosuppression treatment?*

HIV infection, organ transplant recipient, treated with TNF-alpha antagonist (e.g., infliximab, etanercept, others), steroids (equivalent of prednisone ≥15 mg/day for ≥1 month) or other immunosuppressive medication.

Have you been in close contact to someone with infectious TB disease during your lifetime?*
Date of last TB test*

Are you currently exhibiting any of the following symptoms of tuberculosis?

If volunteer exhibits 1 or more symptoms, the form will be forwarded to the RN Nurse Manager to complete part 3 for assessment and recommendations. All recommendations will be discussed with the volunteer and are mandatory. RN Nurse will forward completed form to Volunteer Coordinator for inclusion in their personnel file.

Cough lasting longer than 3 weeks*
Coughing up blood*
Fever, > 101◦F, > 3days*
Weight loss, unplanned*
Night sweats unrelated to menopause*

Have you had any of the following within the last 12 months?

Cough lasting longer than 3 weeks*
Coughing up blood*
Fever, > 101◦F, > 3days*
Weight loss, unplanned*
Night sweats unrelated to menopause*