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TUBERCULOSIS
RISK ASSESSMENT FORM

Race:

Sex:

Hispanic:

US Born:

TB RISK ASSESSMENT INSTRUCTIONS

For the following persons who are at highest risk of developing active tuberculosis disease if they are infected, tuberculin skin tests are considered positive at 5mm of induration or larger.

  • Recent contacts of TB case patients
  • Persons with fibrotic changes on chest radiograph consistent with prior TB
  • Patients with organ transplants and other immunosuppressed patients (e.g., taking the equivalent of >15mg/day
    of prednisone for 1month or longer, or taking tumor necrosis factor inhibitors)
  • Human Immunodeficiency Virus (HIV/AIDS) infected persons

For the following persons with other known high-risk medical conditions or population risks for recent infection, tuberculin skin tests are positive at 10mm of induration or larger:

  • Foreign-born persons, including children, from areas that have a high TB incidence or prevalence (e.g. Latin America and the Caribbean, Africa, Asia, Eastern Europe, and Russia)*
  • Illicit drug users
  • Residents and employees of the following high-risk congregate settings:
    • Correctional institutions
    • Long-term facilities
    • Mental health institutions
    • Child care facilities
    • Hospitals and other health care facilities
    • Residential facilities for patients with acquired immunodeficiency syndrome (AIDS)
    • Homeless shelters
  • Mycobacteriology laboratory personnel
  • Persons with the following clinical conditions that place them at high risk:
    • Silicosis
    • Diabetes mellitus
    • Chronic renal failure/end-stage renal disease
    • Hematologic/reticuloendothelial disease
    • Cancer of head, neck, or lung
    • Intestinal bypass or Gastrectomy
    • Chronic malabsorption syndromes
    • Organ Transplant
  • Infants, children, and adolescents frequently exposed to adults at high risk for TB infection
  • Children < 4 years of age (unless the child falls under another category due to condition or exposure)
  • Travelers who have reported history of prolonged exposure or extended stay in endemic county (e.g. Latin America and the Caribbean, Africa, Asia, Eastern Europe, and Russia)

For persons at low risk for TB, for whom tuberculin testing is not generally indicated, tuberculin skin tests are positive at 15mm of induration or larger:

  • Persons with no known risk factors for TB.

*Additional instructions/recommendations may apply to individuals seeking care through a Civil Surgeon. Please reference recommendations: http://www.cdc.gov/ncidod/dq/civil.htm

TB RISK FACTORS AND MEDICAL CONDITIONS:

Have you ever had a positive skin or blood test?
Have you had any symptoms of TB (cough, fever, night sweats, loss of appetite, weight loss, or fatigue)?
Have you ever been told you have an abnormal chest X-Ray?
In the last 2 years, have you lived with or spent time with someone who has been sick with TB?
Were you born in Africa, Asia, Pacific Islands (except Japan), Central America, South America, Mexico, Eastern Europe, The Caribbean, or the Middle East?
Have you lived or traveled in Africa, Asia, Pacific Islands (except Japan), Central America, South America, Mexico, Eastern Europe, The Caribbean, or the Middle East for more than one month?
Have any members of your household come to the United States from another country?
Have you been exposed to a person who:
  • Is currently in jail or who has been in jail in the past 5 years?
  • Has HIV?
  • Is homeless?
  • Lives in a group home?
  • Uses illegal drugs?
  • Is a migrant farm worker?
Do you have any of the following medical conditions?
  • Diabetes
  • Chronic kidney failure with dialysis
  • Cancer of the neck, head, or lungs
  • Cancer of the blood or lymph system
  • HIV/AIDS
  • Autoimmune disease or immunosuppressive condition
  • Intestinal bypass or gastrectomy
Have you ever been in jail or prison?
Have you ever been an injection drug user?
Have you had an organ transplant?
Have you been around a person sick with active TB disease?
Have you ever worked in a lab that processed TB samples?