- Today's Home Care, Inc.
- 2575 East 14 Street, Unit C1, Brooklyn, NY 11235
- 70-09 Austin Street, 2nd Floor, Forest Hills NY 11375
- Office Phone: 718-650-3358 | Fax: 855-259-2365
- www.TodaysHC.com | [email protected]
ANNUAL TUBERCULOSIS RISK ASSESSMENT
Employee Name:
Title:
1. Have you had a history of temporary or permanent residence (for > 1 month) in a country with a high TB rate (i.e., any country
other than Australia, Canada, New Zealand, the United States, and those in Western or Northern Europe) in the past year?
2. Have you ever been diagnosed with Latent TB infection (LTBI)?
3. Do you have a current or planned immunosuppression, including human immunodeficiency virus infection, receipt of an organ
transplant, treatment with a tumor necrosis factor (TNF)-alpha antagonist (e.g., infliximab, etanercept, or other) chronic steroids
(equivalent of prednisone > 15mg/day for > 1 month) or other immunosuppressive medication?
4. Have you had close contact with someone who has had infectious TB disease in the past year?
b. Did you have adequate personal protection when exposed?
6. Have you ever been diagnosed with TB infection (TB)?
7 . Have you ever been treated for TB infection (TB)?
8 . Have you had any prior diagnostic testing for TB disease?
9. Have you ever had a tuberculin skin test (TST)?
10. When was your last chest x-ray?
Result:
11. Do you currently have any of the following symptoms?
Productive cough for more than 3 weeks
Coughing up blood
Unexplained weight loss
Fever, chills, or drenching night sweats for no known reason
Persistent shortness of breath
Unexplained fatigue for more than 3 weeks
Chest Pain
to Sheepshead Bay
to Forest Hills 71
