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    FOH-25 Tuberculosis Screening (M.25)

    Uploaded by

    Maria Cabañas
    This document is a tuberculosis screening form for federal occupational health. It collects information about an individual's risk factors and history to determine if they need a tuberculosis skin test. The form asks questions about previous positive TB tests, medications, symptoms, risk factors like travel history, medical conditions, and exposure. Based on the answers, the form provides instructions on whether a skin test is indicated and what threshold should be used to read a positive result. If a test is given, spots are marked on the left and right forearm and then read after a set time to determine if the individual needs referral for further evaluation.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    FOH-25 Tuberculosis Screening (M.25)

    Uploaded by

    Maria Cabañas
    537 views1 page
    This document is a tuberculosis screening form for federal occupational health. It collects information about an individual's risk factors and history to determine if they need a tuberculosis skin test. The form asks questions about previous positive TB tests, medications, symptoms, risk factors like travel history, medical conditions, and exposure. Based on the answers, the form provides instructions on whether a skin test is indicated and what threshold should be used to read a positive result. If a test is given, spots are marked on the left and right forearm and then read after a set time to determine if the individual needs referral for further evaluation.

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    © © All Rights Reserved

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    This document is a tuberculosis screening form for federal occupational health. It collects information about an individual's risk factors and history to determine if they need a tuberculosis skin test. The form asks questions about previous positive TB tests, medications, symptoms, risk factors like travel history, medical conditions, and exposure. Based on the answers, the form provides instructions on whether a skin test is indicated and what threshold should be used to read a positive result. If a test is given, spots are marked on the left and right forearm and then read after a set time to determine if the individual needs referral for further evaluation.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    537 views1 page

    FOH-25 Tuberculosis Screening (M.25)

    Uploaded by

    Maria Cabañas
    This document is a tuberculosis screening form for federal occupational health. It collects information about an individual's risk factors and history to determine if they need a tuberculosis skin test. The form asks questions about previous positive TB tests, medications, symptoms, risk factors like travel history, medical conditions, and exposure. Based on the answers, the form provides instructions on whether a skin test is indicated and what threshold should be used to read a positive result. If a test is given, spots are marked on the left and right forearm and then read after a set time to determine if the individual needs referral for further evaluation.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    Federal Occupational Health

    Tuberculosis Screening
    Name:
    _____________________________________________________________

    SSN#
    ______________________

    Male
    Female

    Agency: ________________________

    Job Title
    ______________________

    Date:
    __________

    Location/City: _______________

    Work Phone: ____________________

    Birthdate: ______________

    Please circle the appropriate answer below for each question. This information is strictly confidential and
    will only be used to determine the proper test and reading procedures.
    FOR FOH USE ONLY
    1. Have you ever had positive TB skin test?

    YES

    NO

    2. Are you currently taking steroids (other than


    inhalers), chemotherapy, cancer treating drugs, or
    have you tested HIV+)?

    YES

    NO

    YES

    NO

    3. Do you have a current viral infection (e.g., flu, measles, etc.)


    or have you received a live virus vaccination in the last
    6 weeks (e.g., yellow fever, oral polio, MMR - measles,
    mumps, rubella)?
    4. Do you currently have symptoms of tuberculosis?
    a. Coughing up blood for 2-3 weeks OR
    b. Do you have two or more of the following?
    Chronic cough
    Soaking night sweats
    Chronic fatigue
    Weight loss
    Fever (>100)

    If YES, DO NOT TEST


    If symptoms of TB (see Q#4.)
    refer to PMD for evaluation
    If YES, DO NOT TEST
    Refer to PMD for evaluation

    If YES, DEFER TESTING


    Save form and plan to test client
    after well for 6 weeks.
    .

    YES

    NO

    YES

    NO

    YES

    NO

    7. Were you born in Asia, Africa, Latin America, or the


    Caribbean?

    YES

    NO

    8. Do you have any of the following?


    Diabetes
    Cancer
    Silicosis
    Gastrectomy
    Underweight
    Kidney failure

    YES

    NO

    5. Do you or have you had any of the following:


    Blood transfusion before 1985?
    Multiple sex partners?
    Same sex partners (i.e., male/male)?
    Contaminated needle stick?
    Use injectable drugs?
    6. Have you had household or similar close contact with
    someone who is known to have active TB in the last 3
    months?

    TEST
    If YES, Refer to PMD for
    evaluation;
    Consult FOH POC regarding
    employee return to work.

    TEST
    If YES, read test
    positive @ 5mm..

    TEST
    If YES, read test
    positive @ 10mm..

    TEST
    Read test positive @ 15mm..

    If all NO

    RESULTS: FOR FOH USE ONLY

    Initial PPD Results

    Post-exposure

    Check ONE:

    FOH Health Center (stamp)

    2nd PPD Results


    age > 55

    Client declined

    Date applied:_______________ L/R

    Date applied: _______________ L/R

    PPD NOT indicated (Pos. Hx.)

    Applied by ___________________

    Applied by ___________________

    Baseline FOH PPD

    FOH

    other provider

    FOH

    other provider

    Periodic FOH PPD

    Manufacturer:_________________

    Manufacturer:_________________

    PPD Post-exposure OR

    Lot#___________ Exp._________

    Lot#___________ Exp._________

    baseline for > age 55 (requires 2 PPDs)

    Date read: ___________________

    Date read: ___________________

    Read by: ____________________

    Read by: ____________________

    _________mm. induration

    _________mm. induration

    Check if applicable:
    Client referred
    Client did not return for reading

    Positive (referred)

    Negative

    Positive (referred)

    Negative

    This form is presented as a guide and should not replace professional clinical judgment. For additional information please refer to FOH Tuberculosis Orientation: A Self Study Guide
    FOH-25

    Rev.5/11/99

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