Have you ever had close contact with persons with known or active TB (tuberculosis) disease?*

Yes

No

A - Afghanistan, Algeria, Angola, Argentina, Armenia, Azerbaijan
B - Bahrain, Bangladesh, Belarus, Belize, Benin, Bhutan, Bolivia (Plurinational State of), Bosnia and Herzegovina, Botswana, Brazil, Brunei Darussalam, Bulgaria, Burkina Faso, Burma, Burundi
C - Cabo Verde, Cambodia, Cameroon, Central African Republic, Chad, China, Colombia, Comoros, Congo, Côte d’Ivoire
D - Dem Ppl’s Rep of Korea, Dem Rep of Congo, Djibouti, Dominican Republic
E - Ecuador, El Salvador, Equatorial Guinea Eritrea, Estonia, Ethiopia
F- Fiji
G - Gabon, Gambia, Georgia, Ghana, Guatemala, Guinea, Guinea-Bissau, Guyana
H - Haiti, Hong Kong, Honduras
I - India, Indonesia, Iran (Islamic Republic of), Iraq
K - Kazakhstan, Kenya, Kiribati, Kuwait, Kyrgyzstan
L - Lao Ppl’s Democratic Rep, Latvia, Lesotho, Liberia, Libya, Lithuania
M - Madagascar, Malawi, Malaysia, Maldives, Mali, Marshall Islands, Mauritania, Mauritius, Mexico, Micronesia, Mongolia, Morocco, Mozambique, Myanmar
N- Namibia, Nauru, Nepal, Nicaragua, Niger, Nigeria, Niue
P - Pakistan, Palau, Panama, Papua New Guinea, Paraguay, Peru, Philippines, Poland, Portugal
Q - Qatar
R - Republic of Korea, Republic of Moldova, Romania, Russian Federation, Rwanda
S- Saint Vincent/Grenadines, Sao Tome and Principe, Senegal, Serbia, Seychelles, Sierra Leone, Singapore, Solomon Islands, Somalia, South Africa, South Sudan, Sri Lanka, Sudan, Suriname, Swaziland
T - Taiwan, Tajikistan, Tanzania, Thailand, Timor-Leste, Togo, Trinidad and Tobago, Tunisia, Turkey, Turkmenistan, Tuvalu
U - Uganda, Ukraine, United Rep of Tanzania, Uruguay, Uzbekistan
V - Vanuatu, Venezuela, Viet Nam
Y - Yemen
Z - Zambia, Zimbabwe

Have you been a resident and/or employee of high-risk congregate settings (e.g., correctional facilities, long-term care facilities, and homeless shelters)?*

Yes

No

Have you been a volunteer or health-care worker who served clients who are at increased risk for active TB disease?*

Yes

No

Have you ever been a member of any of the following groups that may have an increased incidence of latent M. tuberculosis infection or active TB disease: medically underserved, low-income, or those abusing drugs or alcohol?*

Yes

No