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REWARD HOME CARE

TUBERCULOSIS (TB) SCREENING QUESTIONNAIRE
Initial / Annual Health Screening

Purpose: This questionnaire is used to document tuberculosis risk and symptom screening for Reward Home Care personnel with direct consumer contact. Complete at hire and as required by agency policy and applicable Pennsylvania requirements. Answer all questions based on your current condition and the period since your last TB evaluation.

A. TB EXPOSURE / RISK ASSESSMENT

1. Since your last TB evaluation, have you had close or prolonged contact with anyone known or suspected to have active tuberculosis (TB)?
Yes
No
2. Since your last TB evaluation, have you worked or volunteered in a setting where TB exposure or ongoing TB transmission was reported?
Yes
No
3. Since your last TB evaluation, have you lived in, traveled to, or frequently visited a country or setting where TB is common for one month or more?
Yes
No
4. Do you have a medical condition or take medication that significantly weakens your immune system and may increase your risk of developing active TB?
Yes
No

B. TB SYMPTOM SCREEN

5. Do you currently have a cough lasting 3 weeks or longer?
Yes
No
6. Are you coughing up blood or blood-streaked sputum?
Yes
No
7. Do you have unexplained chest pain associated with breathing or coughing?
Yes
No
8. Have you had unexplained fever or recurring chills?
Yes
No
9. Have you had unexplained night sweats?
Yes
No
10. Have you had unexplained weight loss?
Yes
No
11. Have you had unexplained loss of appetite?
Yes
No
12. Have you had unusual or persistent fatigue / weakness?
Yes
No

C. PRIOR TB HISTORY

13. Have you ever had a positive TB skin test (TST/PPD) or positive TB blood test (IGRA such as QuantiFERON or T-SPOT)?
Yes
No
14. Have you ever been diagnosed with latent TB infection (LTBI)?
Yes
No
15. Have you ever been diagnosed with active TB disease?
Yes
No
16. If you previously had a positive TB test or LTBI, did you complete recommended treatment?
Yes
No
17. If you previously had active TB disease, did you complete treatment and receive medical clearance?
Yes
No
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