California School Employee Tuberculosis (TB) Risk Assessment Questionnaire
(for pre-K, K-12 schools and community college employees, volunteers and contractors)

• Use of this questionnaire is required by California Education Code sections 49406 and 87408.6, and Health and Safety Code sections 1597.055 and 121525-121555.^

• The purpose of this tool is to identify adults with infectious tuberculosis (TB) to prevent them from spreading disease.

• Do not repeat testing unless there are new risk factors since the last negative test.

• Do not treat for latent TB infection (LTBI) until active TB disease has been excluded:
For individuals with signs or symptoms of TB disease or abnormal chest x-ray consistent with TB disease, evaluate for active TB disease with a chest x-ray, symptom screen, and if indicated, sputum AFB smears, cultures and nucleic acid amplification testing.
A negative tuberculin skin test (TST) or interferon gamma release assay (IGRA) does not rule out active TB disease.

Name of Person Assessed for TB Risk Factors: _________________________________________________

Assessment Date: _________________________	Date of Birth: _________________________

History of Tuberculosis Disease or Infection (Check appropriate box below)

☐^Yes
• If there is a documented history of positive TB test or TB disease, then a symptom review and chest x-ray (if none performed in the previous 6 months) should be performed at initial hire by a physician, physician assistant, or nurse practitioner. If the x-ray does not have evidence of TB, the person is no longer required to submit to a TB risk assessment or repeat chest x-rays.

☐^No ^(Assess ^for ^Risk ^Factors ^for ^Tuberculosis ^using ^box ^below)

TB testing is recommended if any of the 3 boxes below are checked

☐^One ^or ^more ^sign(s) ^or ^symptom(s) ^of ^TB ^disease
• TB symptoms include prolonged cough, coughing up blood, fever, night sweats, weight loss, or excessive fatigue.

☐^Birth, ^travel, ^or ^residence ^in ^a ^country ^with ^an ^elevated ^TB ^rate ^for ^at ^least ^1 ^month
• Includes countries other than the United States, Canada, Australia, New Zealand, or Western and North European countries.
• Interferon gamma release assay (IGRA) is preferred over tuberculin skin test (TST) for non-US-born persons.

☐^Close ^contact ^to ^someone ^with ^infectious ^TB ^disease ^during ^lifetime
Treat for LTBI if TB test result is positive and active TB disease is ruled out

^The law requires that a health care provider administer this questionnaire. A health care provider, as defined for this purpose, is any organization, facility, institution or person licensed, certified or otherwise authorized or permitted by state law to deliver or furnish health services. A Certificate of Completion should be completed after screening is completed (page 3).

6/25/18

Certificate of Completion Tuberculosis Risk Assessment and/or Examination

To satisfy job-related requirements in the California Education Code, Sections 49406 and 87408.6 and the California Health and Safety Code, Sections 1597.055, 121525, 121545 and 121555.

First and Last Name of the person assessed and/or examined:

__________________________________________________

Date of assessment and/or examination: ______mo./______day/______yr.

Date of Birth: ______mo./______day/______yr.

The above named patient has submitted to a tuberculosis risk assessment. The patient does not have risk factors, or if tuberculosis risk factors were identified, the patient has been examined and determined to be free of infectious tuberculosis.

X___________________________________________________________________

Signature of Health Care Provider completing the risk assessment and/or examination

Please print, place label or stamp with Health Care Provider Name and Address (include Number, Street, City, State, and Zip Code):

6/25/18