TB Survey

ANNUAL TUBERCULOSIS SCREENING QUESTIONNAIRE

This form is to be completed annually by all FIELD STAFF, CONTRACTUAL STAFF, and OFFICE STAFF. This form is also to be completed upon return from a Leave of Absence lasting longer than 30 days or upon return from travel outside of the United States.

Please indicate if you are experiencing any of the following symptoms for two to three weeksor longer at any time during the past year:

NO EVIDENCE OF IDENTIFIALBE PULMONARY TUBERCULOSIS OR CONTAGIUM HAS BEEN RECOGNIZED AT THE TIME OF COMPLETION OF THIS QUESTIONNAIRE.