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TB Questionnaire Form
Please don't fill out this input box.
First Name
*
Last Name
*
Date of Birth
Start of Term
*
(month/year)
Have you ever had close contact with persons with known or active TB (tuberculosis) disease?
*
Yes
No
If yes, what country (check the list below, and type in all countries that apply)
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
If yes above, where?
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
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