ANNUAL TUBERCULOSIS QUESTIONNAIRE

Anuual Tuberculosis Questionnaire

"*" indicates required fields

Employee Name:*

For personnel who have a known positive PPD and previously negative chest x-ray, you are requested to complete this questionnaire with either a yes or no.

HAVE YOU NOTICED ANY OF THE FOLLOWING?

Unexplained Fevers
Night Sweats
Unintentional weight loss
Cough
Hoarseness
Bloody Sputum
Have you completed INH therapy?
Have you ever had a BCG vaccine?
Have you had an x-ray while employed here?
MM slash DD slash YYYY
Have you had an x-ray while employed here?
MM slash DD slash YYYY