Clovis Unified School District

ADULT TUBERCULOSIS (TB) RISK ASSESSMENT
(To satisfy California Education Code Section 49406 and Health Code Sections 121525-121555)

Employee Name	Employee ID Number	Status

______________________________________________________________________________ Phone Number

Site/Department	Position Title

I hereby give consent to administer the Adult Tuberculosis (TB) Risk Assessment. Furthermore, I certify that my answers below are true and correct.

Employee Signature	Date

To be administered by a licensed health care provider (physician, physician assistant, nurse practitioner, registered nurse)
	
History of positive TB test orTB disease
	
New Employee: If yes, a symptom review and chest x-ray should be performed at initial hire (if none performed in previous 6 months). Existing Employee: Continue with questions below:
	
Risk Factors
	
1.	One or more signs and symptoms of TB (prolonged cough, coughing up blood, fever, night sweats, weight loss, excessive fatigue) Note: A chest x-ray and/or sputum examination may be necessary to rule out infectious TB.
	
2.	Close contact with someone with infectiousTB disease
	
3.	Birth in high TB-prevalence country**
(**Any country other than the United States, Canada, Australia, New Zealand, or a country in Western or Northern Europe.)
	
4.	Travel to high TB-prevalence country** for more than1 month
(**Any country other than the United States, Canada, Australia, New Zealand, or a country in Western or Northern Europe.)
	
5.	Current or former residence or work in a correctional facility, long-term care facility, hospital, or homeless shelter

All answers are NO. The above-named employee has submitted to a Tuberculosis Risk Assessment and does not have risk factors and therefore does not need to receive the PPD at this time.

Some answers are YES. If there is a “Yes” response to any of the questions 1-5 above, then a Tuberculin Skin Test (TST) or Interferon Gamma Release Assay (IGRA) may be performed.
A positive test should be followed by a chest x-ray, and if normal, treatment for TB infection considered.

Employee elects Clovis USD to administer Tuberculin Skin Test (TST). Employee elects outside medical examination.

	/RN	
Signature/Title of Administering Personnel	Date of Risk Assessment

Clovis Unified School District	1680 David E. Cook Way	Clovis CA 93611	559 327-9565

Original: Human Resources	9.1.2020