Слесарь-сборщиков металлоконструкций

Описание

TUBERCULOSIS (TB) RISK ASSESSMENT
To be completed by health care providers ONLY
if required based on TB Screening Form




Student Name: _______________________________ Student ID #:_________________________________________ Persons with any of the following risk factors are candidates for either Mantoux tuberculin skin test (TST) or Interferon Gam ma 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. Does the student have signs or symptoms of active pulmonary tuberculosis disease?
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
Unexpected weight loss
Night sweats
Fever
Proceed with additional evaluation to exclude active tuberculosis disease including tuberculin skin testing (or IGRA) , 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”. Th e TST interpretation
should be based on mm of induration as well as risk factors).**

Date given: _____/______/________ Date Read: ______/______/_______

Results: ___________mm of induration **Interpretation: Positive ______ Negative ______
Interpretation Guidelines :
> 5mm is positive:
• Recent close contacts of an individuals with infectious TB
• Persons with fibrotic changes on prior chest x -ray,
consistent with past TB disease
• Organ transplant recipients and other immunosuppressed
persons (including receiving  15 mg/d of prednisone for
 1 month)
• Persons with HIV/ Aids
> 10 mm is positive:
• Recent arrivals to the U.S. (< 5> 10 mm is positive continued:
• 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, 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
_________________________________________________________________________________________________________________________ 3. Interferon Gamma Release Assay (IGRA) Date Obtained: _____/_____/_______ (circle method): QFT -G QFT -GIT T -Spot Other_____ ____ _______ __________ 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 ______
_________________________________________________________________________________________________________________________
HEALTH CARE PROVIDER:
Name: __________________________________________________________ Signature: ________________________________________________
Address: ________________________________________________________ Phone: (________) ______________________________________ ___
Fall 2024