EmailMeForm
Occupational Health & Safety TB Screening - R
Tuberculosis Symptom Screening Questionnaire for Raleigh Hospital Volunteers. This is due annually for WakeMed volunteers during your birthday month. If this is not your birthday month, do not fill out. Please answer all questions and provide detail for any question that is answered with a yes.
Volunteer Name
*
First
Last
Date of Birth - Please complete this form only if it is your birthday month. If it is not your birthday month, no action is needed at this time. Please contact the Volunteer Services Office if you have any questions.
*
MM
/
DD
/
YYYY
1. Have you experienced any of the following symptoms in the past year?
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a) Productive cough for more than 3 weeks
Please select
Yes
No
b) Coughing up blood (Hemoptysis)
Please select
Yes
No
c) Unexplained weight loss, unexplained fatigue (tiredness)
Please select
Yes
No
d) Fever, chills, or night sweats for no known reason
Please select
Yes
No
e) Persistent shortness of breath chest pain
Please select
Yes
No
2. Please answer each of the following Statements:
*
a.) Exposure to anyone with active tuberculosis in the past year?
Please select
Yes
No
b) Do you have a weakened immune system?
Please select
Yes
No
c) Do you take medications that may weaken your immune system?
Please select
Yes
No
d) Have you ever received a BCG Vaccine?
Please select
Yes
No
e) Have you ever had a positive TB Skin Test or QGOLD?
Please select
Yes
No
If you answered "yes" to "E", did you receive treatment?
Please select
Yes
No
Please Complete only if you answer yes to "E"
Date
Location
If you answered "yes" to "E", what is the date and location of your last chest x-ray?
Please complete for any questions that you answered "Yes"
Please provide a detailed description to any questions answered "Yes"
I declare that my answers and statements are correctly recorded, complete, and true to the best of my knowledge. I understand if I develop any of the symptoms listed above, I am to schedule an appointment with Occupational Health using the MyOccHealth Portal or call 919-350-7370 for assistance.
Sign below:
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Clear
Volunteer Name:
*
First
Middle
Last
By typing in my name, I understand that this will serve as my electronic signature.
Date
*
MM
/
DD
/
YYYY
Phone
*
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Please use SUBMIT button below to send in your information to the Occupational Health & Safety Services office.
OFFICE USE ONLY:
________ No indication of active TB at this time.
Date Reviewed: _____/_____/_____
________Further evaluation needed.
Date Volunteer Contacted: _____/_____/_____
Action Taken: _____________________________________________________________
Date of follow-up exam: _____/_____/_____
Exam outcome: _______________________________________
Signature: _____________________________
Title: □ RN □ LPN □ MD □ Other ___________________________
