Student and Employee Health

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HCP Individual TB Risk Assessment

* - Required Fields

First Name* 
Last Name* 
Are you an employee or a student?*  
Employee ID*
Job Title*
Student ID*
School*
Department*
If Other, please specify here.
Email Address* 
Healthcare personnel (HCP) should be considered at increased risk for TB if any of the following statements are marked "Yes"
Temporary or permanent residence of ≥ 1 month in a country with a high TB rate (since the last TB test)*
Any country other than the United States, Canada, Australia, New Zealand, and those in Northern Europe or Western Europe

Current or planned immunosuppression*
including human immunodeficiency virus (HIV) infection, organ transplant recipient, treatment with a TNF-alpha antagonist (e.g., infliximab, etanercept, or other), chronic steroids (equivalent of prednisone ≥15 mg/day for ≥1 month) or other immunosuppressive medication

Close contact with someone who has had infectious TB disease since the last TB test*
(exposure within 3 feet without use of respiratory mask)

Signature*