Tuberculosis (TB)Screening Questionnaire

Questionnaire — Student
Please answer the following questions:

Have you ever had a positive TB skin test?
Have you ever had a positive TB skin test?
Have you ever had close contact with anyone who was sick with TB?
Have you ever had close contact with anyone who was sick with TB?
Were you born in one of the countries listed below and arrived in the US within the past 5 years?*
Were you born in one of the countries listed below and arrived in the US within the past 5 years?*
Have you ever travelled** to/in one or more of the countries listed below?
Have you ever travelled** to/in one or more of the countries listed below?
Have you ever been vaccinated with BCG?
Have you ever been vaccinated with BCG?

*future CDC updates may eliminate the 5 year time frame*
**the significance of the travel exposure should be discussed with a health care provider and evaluated


  • Afghanistan
  • Algeria
  • Angola
  • Argentina
  • Armenia
  • Azerbaijan
  • Bahrain
  • Bangladesh
  • Belarus
  • Belize
  • Benin
  • Bhutan
  • Bolivia (Plurinational State of)
  • Bosnia and Herzegovina
  • Botswana
  • Brazil
  • Brunei Darussalam
  • Bulgaria
  • Burkina Faso
  • Burundi
  • Cambodia
  • Cameroon
  • Cape Verde
  • Central African Republic
  • Chad
  • China
  • Colombia
  • Comoros
  • Congo
  • Cook Islands
  • Côte d’Ivoire
  • Croatia
  • Democratic People’s Republic of Korea
  • Democratic Republic of the Congo
  • Djibouti
  • Dominican Republic
  • Ecuador
  • El Salvador
  • Equatorial Guinea
  • Eritrea
  • Estonia
  • Ethiopia
  • French Polynesia
  • Gabon
  • Gambia
  • Georgia
  • Ghana
  • Guam
  • Guatemala
  • Guinea
  • Guinea-Bissau
  • Guyana
  • Haiti
  • Honduras
  • India
  • Indonesia
  • Iraq
  • Japan
  • Kazakhstan
  • Kenya
  • Kiribati
  • Kuwait
  • Kyrgyzstan
  • Lao People’s Democratic Republic
  • Latvia
  • Lesotho
  • Liberia
  • Libyan Arab
  • Jamahiriya
  • Lithuania
  • Madagascar
  • Malawi
  • Malaysia
  • Maldives
  • Mali
  • Marshall Islands
  • Mauritania
  • Mauritius
  • Micronesia (Federated States of)
  • Mongolia
  • Montenegro
  • Morocco
  • Mozambique
  • Myanmar
  • Namibia
  • Nepal
  • Nicaragua
  • Niger
  • Nigeria
  • Pakistan
  • Palau
  • Panama
  • Papua New Guinea
  • Paraguay
  • Peru
  • Philippines
  • Poland
  • Portugal
  • Qatar
  • Republic of Korea
  • Republic of Moldova
  • Romania
  • Russian Federation
  • Rwanda
  • Saint Vincent and the Grenadines
  • Sao Tome and Principe
  • Senegal
  • Serbia
  • Seychelles
  • Sierra Leone
  • Singapore
  • Solomon Islands
  • Somalia
  • South Africa
  • Sri Lanka
  • Sudan
  • Suriname
  • Swaziland
  • Syrian Arab Republic
  • Tajikistan
  • Thailand
  • The former Yugoslav Republic of Macedonia
  • Timor-Leste
  • Togo
  • Tonga
  • Trinidad and Tobago
  • Tunisia
  • Turkey
  • Turkmenistan
  • Tuvalu
  • Uganda
  • Ukraine
  • United Republic of Tanzania
  • Uruguay
  • Uzbekistan
  • Vanuatu
  • Venezuela (Bolivarian Republic of)
  • Vietnam
  • Yemen
  • Zambia
  • Zimbabwe

Analysis

If the answer is YES to any of the above questions, Ottawa University requires that a health care provider complete a tuberculosis risk assessment (to be completed within 6 months prior to the start of classes).

If the answer to ALL of the above questions is NO, no further testing or further action is required.