Tuberculosis (TB)Screening Questionnaire

Have you ever had a positive TB skin test?:

Yes

No

Have you ever had close contact with anyone who was sick with TB?:

Yes

No

Were you born in one of the countries listed below and arrived in the US within the past 5 years?*:

Yes

No

Have you ever travelled** to/in one or more of the countries listed below?:

Yes

No

Have you ever been vaccinated with BCG?:

Yes

No

Student Name*:

Student ID Number*:

Cell Phone Number:

Date*: