Tuberculosis Form For College

Tuberculosis Screening and Targeted Testing of College and University Students
University of Bridgeport Student Health Services

Name_________________________Date___________ Student ID__________________
Part I: Tuberculosis (TB) Screening Questionnaire (to be completed by incoming students)
Please answer the following questions:
Have you ever had close contact with persons known or suspected to have active TB disease?  Yes  No
Were you born in one of the countries listed below that have a high incidence of active TB disease?  Yes  No
(If yes, please CIRCLE the country, below)
Afghanistan Côte d'Ivoire Japan Nicaragua Sudan

Algeria Croatia Kazakhstan Niger Suriname
Angola Democratic People's Republic of Kenya Nigeria Swaziland
Argentina Korea Kiribati Pakistan Syrian Arab Republic
Armenia Democratic Republic of the Kuwait Palau Tajikistan
Azerbaijan Congo Kyrgyzstan Panama Thailand
Bahrain Djibouti Lao People's Democratic Papua New Guinea The former Yugoslav
Bangladesh Dominican Republic Republic Paraguay Republic of
Belarus Ecuador Latvia Peru Macedonia
Belize El Salvador Lesotho Philippines Timor-Leste
Benin Equatorial Guinea Liberia Poland Togo
Bhutan Eritrea Libyan Arab Jamahiriya Portugal Tunisia
Bolivia (Plurinational State of) Estonia Lithuania Qatar Turkey
Bosnia and Herzegovina Ethiopia Madagascar Republic of Korea Turkmenistan
Botswana Fiji Malawi Republic of Moldova Tuvalu
Brazil Gabon Malaysia Romania Uganda
Brunei Darussalam Gambia Maldives Russian Federation Ukraine
Bulgaria Georgia Mali Rwanda United Republic of
Burkina Faso Ghana Marshall Islands Saint Vincent and the Tanzania
Burundi Guam Mauritania Grenadines Uruguay
Cambodia Guatemala Mauritius Sao Tome and Principe Uzbekistan
Cameroon Guinea Micronesia (Federated States Senegal Vanuatu
Cape Verde Guinea-Bissau of) Seychelles Venezuela (Bolivarian
Central African Republic Guyana Mongolia Sierra Leone Republic of)
Chad Haiti Morocco Singapore Viet Nam
China Honduras Mozambique Solomon Islands Yemen
Colombia India Myanmar Somalia Zambia
Comoros Indonesia Namibia South Africa Zimbabwe
Congo Iraq Nepal Sri Lanka
Source: World Health Organization Global Health Observatory, Tuberculosis Incidence 2010. Countries with incidence rates of ≥ 20 cases per 100,000
population. For future updates, refer to http://apps.who.int/ghodata
Have you had frequent or prolonged visits* to one or more of the countries listed above with a high  Yes  No
prevalence of TB disease? (If yes, CHECK the countries, above)
Have you been a resident and/or employee of high-risk congregate settings (e.g., correctional facilities,  Yes  No
long-term care facilities, and homeless shelters)?
Have you been a volunteer or health-care worker who served clients who are at increased risk for active  Yes  No
TB disease?
Have you ever been a member of any of the following groups that may have an increased incidence of  Yes  No
latent M. tuberculosis infection or active TB disease – medically underserved, low-income, or abusing
drugs or alcohol?
If the answer is YES to any of the above questions, you are required to receive TB Testing prior to the start of
the semester
If the answer to all of the above questions is NO, no further testing or further action is required.
Part II. Clinical Assessment by Health Care Provider
Clinicians should review and verify the information in Part I. Persons answering YES to any of the questions in
Part I are candidates for either Mantoux tuberculin skin test (TST) or Interferon Gamma Release Assay (IGRA),
unless a previous positive test has been documented.
History of a positive TB skin test or IGRA blood test? (If yes, document below) Yes _____ No _____
History of BCG vaccination? (If yes, consider IGRA if possible.) Yes _____ No _____
1. TB Symptom Check1
Does the student have signs or symptoms of active pulmonary tuberculosis disease? Yes _____ No _____
If No, proceed to 2 or 3
If yes, check below:
 Cough (especially if lasting for 3 weeks or longer) with or without sputum production
 Coughing up blood (hemoptysis)
 Chest pain
 Loss of appetite
 Unexplained weight loss
 Night sweats
 Fever
Proceed with additional evaluation to exclude active tuberculosis disease including tuberculin skin testing, chest
x-ray, and sputum evaluation as indicated.
2. Tuberculin Skin Test (TST)
(TST result should be recorded as actual millimeters (mm) of induration, transverse diameter; if no induration,
write “0”. The TST interpretation should be based on mm of induration as well as risk factors.)**
Date Given: ____/____/____ Date Read: ____/____/____
M D Y M D Y
Result: ________ mm of induration **Interpretation: positive____ negative____
Date Given: ____/____/____ Date Read: ____/____/____

M D Y M D Y
Result: ________ mm of induration **Interpretation: positive____ negative____
**Interpretation guidelines
>5 mm is positive:
 Recent close contacts of an individual with infectious TB
 persons with fibrotic changes on a prior chest x-ray, consistent with past TB disease
 organ transplant recipients and other immunosuppressed persons (including receiving equivalent of >15 mg/d of prednisone for >1 month.)
 HIV-infected persons
>10 mm is positive:
 recent arrivals to the U.S. (<5 years) from high prevalence areas or who resided in one for a significant* amount of time
 injection drug users
 mycobacteriology laboratory personnel
 residents, employees, or volunteers in high-risk congregate settings
 persons with medical conditions that increase the risk of progression to TB disease including silicosis, diabetes mellitus, chronic renal
failure, certain types of cancer (leukemias and lymphomas, cancers of the head, neck, or lung), gastrectomy or jejunoileal bypass and
weight loss of at least 10% below ideal body weight.
>15 mm is positive:
 persons with no known risk factors for TB who, except for certain testing programs required by law or regulation, would otherwise not be
tested.
* The significance of the travel exposure should be discussed with a health care provider and evaluated.
Tuberculosis Screening and Targeted Testing of College and University Students
1
CDC. Controlling Tuberculosis in the United States: Recommendations from the American Thoracic Society, CDC, and the Infectious
Diseases Society of America. MMWR November 2005; 54 (No. RR-12): 4-5.
3. Interferon Gamma Release Assay (IGRA)
Date Obtained: ____/____/____ (specify method) QFT-GIT T-Spot other_____

M D Y
Result: negative___ positive___ indeterminate___ borderline___ (T-Spot only)
Date Obtained: ____/____/____ (specify method) QFT-GIT T-Spot other_____

M D Y
Result: negative___ positive___ indeterminate___ borderline___ (T-Spot only)
4. Chest x-ray: (Required if TST or IGRA is positive)
Date of chest x-ray: ____/____/____ Result: normal____ abnormal_____

M D Y
Part III. Management of Positive TST or IGRA

All students with a positive TST or IGRA with no signs of active disease on chest x-ray should receive a
recommendation to be treated for latent TB with appropriate medication. However, students in the following groups
are at increased risk of progression from LTBI to TB disease and should be prioritized to begin treatment as soon as
possible.
 Infected with HIV
 Recently infected with M. tuberculosis (within the past 2 years)
 History of untreated or inadequately treated TB disease, including persons with fibrotic changes on chest radiograph
consistent with prior TB disease
 Receiving immunosuppressive therapy such as tumor necrosis factor-alpha (TNF) antagonists, systemic
corticosteroids equivalent to/greater than 15 mg of prednisone per day, or immunosuppressive drug therapy following
organ transplantation
 Diagnosed with silicosis, diabetes mellitus, chronic renal failure, leukemia, or cancer of the head, neck, or lung
 Have had a gastrectomy or jejunoileal bypass
 Weigh less than 90% of their ideal body weight
 Cigarette smokers and persons who abuse drugs and/or alcohol
••Populations defined locally as having an increased incidence of disease due to M. tuberculosis, including medically underserved, low-income
populations
______Student agrees to receive treatment

______Student declines treatment at this time
_________________________________________________________ ________________________________
Health Care Professional Signature Date
University of Bridgeport
Student Health Services
Prepared originally by ACHA’s Tuberculosis Guidelines Task Force

Revised by Emerging Public Health Threats and Emergency Response Coalition

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Tuberculosis Screening and Targeted Testing of College and University Students

University of Bridgeport Student Health Services

Afghanistan Côte d'Ivoire Japan Nicaragua Sudan

Date Given: // Date Read: //

3. Interferon Gamma Release Assay (IGRA)

Date Obtained: // (specify method) QFT-GIT T-Spot other_

Date Obtained: // (specify method) QFT-GIT T-Spot other_

4. Chest x-ray: (Required if TST or IGRA is positive)

Date of chest x-ray: // Result: normal abnormal_

Part III. Management of Positive TST or IGRA

______Student agrees to receive treatment

Prepared originally by ACHA’s Tuberculosis Guidelines Task Force

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