APPENDIX B

Part I: Tuberculosis (TB) Screening Questionnaire

Please answer the following questions:

Have you ever had close contact with persons known or suspected to have active TB disease? _Yes No

Were you born in one of the countries listed below that have a high incidence of active TB disease? _Yes No
(If yes, please CIRCLE the country, below)
Afghanistan COte d'Ivoire Kenya Nicaragua South Africa
Algeria Democratic People's Republic Kiribati Niger South Sudan
Angola of Korea Kuwait Nigeria Sri Lanka
Argentina Democratic Republic of the Kyrgyzstan Niue Sudan
Armenia Congo Lao People's Democratic Pakistan Suriname
Azerbaijan Djibouti Republic Palau Swaziland
Bahrain Dominican Republic Latvia Panama Tajikistan
Bangladesh Ecuador Lesotho Papua New Guinea Thailand
Belarus El Salvador Liberia Paraguay Timor-Leste
Belize Equatorial Guinea Libya Peru Togo
Benin Eritrea Lithuania Philippines Trinidad and Tobago
Bhutan Estonia Madagascar Poland Tunisia
Bolivia {Plurinational State of) Ethiopia Malawi Portugal Turkey
Bosnia and Herzegovina Fiji Malaysia Qatar Turkmenistan
Botswana Gabon Maldives Republic of Korea Tuvalu
Brazil Gambia Mali Republic of Moldova Uganda
Brunei Darussalam Georgia Marshall Islands Romania Ukraine
Bulgaria Ghana Mauritania Russian Federation United Republic of
Burkina Faso Guatemala Mauritius Rwanda Tanzania
Burundi Guinea Mexico Saint Vincent and the Uruguay
Caba Verde Guinea-Bissau Micronesia (Federated States Grenadines Uzbekistan
Cambodia Guyana on Sao Tome and Principe Vanuatu
Cameroon Haiti Mongolia Senegal Venezuela (Bolivarian
Central African Republic Honduras Morocco Serbia Republic of)
Chad India Mozambique Seychelles Viet Nam
China Indonesia Myanmar Sierra Leone Yemen
Colombia Iran (Islamic Republic of) Namibia Singapore Zambia
Comoros Iraq Nauru Solomon Islands Zimbabwe
Congo Kazakhstan Nepal Somalia

Source: World Health Orgamzat1on Global Health Observatory, Tuberculosis Incidence 2012. Countries wtth mc1dence rates of~ 20 cases per
100,000 population. For future updates, refer to http://apps.who.int/ghodata.

Have you had frequent or prolonged visits* to one or more of the countries listed above with a high _Yes _No
prevalence of TB disease? (If yes, CHECK the countries, above)

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

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

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

If the answer is YES to any of the above questions, Dakota College at Bottineau requires that you receive TB testing as
soon as possible but at least prior to the start of the subsequent semester.
If the answer to all of the above questions is NO, no further testing or further action is required.
* The significance of the travel exposure should be discussed with a health care provider and evaluated.

Student Name:
------------------- ID# ------------ Date of Birth-------
 Part II. Clinical Assessment by Health Care Provider
Clinicians should review and verify the information in Part I. Persons answering YES to any of the questions in
Part I are candidates for either Mantoux tuberculin skin test {TST) or Interferon Gamma Release Assay {IGRA), unless a
previous positive test has been documented.

History of a positive TB skin test or IGRA blood test? {If yes, document below) _ _Yes _ _No

History of BCG vaccination? {If yes, consider IGRA if possible.) _ _Yes _ _No

1. TB Symptom Check
Does the student have signs or symptoms of active pulmonary tuberculosis disease? _ _Yes No
If No, proceed to 2 or 3
If yes, check below:
o Cough {especially if lasting for 3 weeks or longer) with or without sputum production
o Coughing up blood {hemoptysis)
o Chest pain
o Loss of appetite
o Unexplained weight loss
o Night sweats
o Fever
Proceed with additional evaluation to exclude active tuberculosis disease including tuberculin skin testing, chest x-ray,
and sputum evaluation as indicated.

2. Tuberculin Skin Test (TST)

{TST result should be recorded as actual millimeters {mm) of induration, transverse diameter; if no induration, write "O".
The TST interpretation should be based on mm of induration as well as risk factors.)**
1. Date Given:__/__/__ Date Read:__/__/__
M D Y M D Y
Result: ____ mm of induration **Interpretation: positive__ negative_ _

2. Date Given:__/__/__ Date Read:__/__/__

M D Y M D Y
Result: ____ mm of induration **Interpretation: positive_ _ negative__

"'*Interpretation guidelines
>5 mm is positive:
• recent dose contacts of an individual with infectious TB
• persons with fibrotic changes on a prior chest x-ray, consistent with past TB disease
• organ transplant recipients and other immunosuppressed persons (including receiving equivalent of >15 mg/d of prednisone for >1 month.)
• HIV-infected persons
>10 mm is positive:
• recent arrivals to the U.S. {<5 years) from high prevalence areas or who resided in one for a significant* amount of time
• injection drug users
• mycobacteriology laboratory personnel
• residents, employees, or volunteers in high•risk congregate settings
• persons with medical conditions that increase the risk of progression to TB disease including silicosis, diabetes mellitus, chronic renal failure, certain types
of cancer (leukemias and lymphomas, cancers of the head, neck, or lung), gastrectomy or jejunoileal bypass and weight loss of at least 10% below ideal
body weight.

>15 mm is positive:
• persons with no known risk factors for TB who, except for certain testing programs required by law or regulation, would otherwise not be tested.

Student Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ID # _ _ _ _ _ _ _ _ _ _ Date of Birth_ _ _ _ __

 3. Interferon Gamma Release Assay (IGRA) - See attached results from independent laboratory

4. Chest x-ray: (Required if TST or IGRA is positive)

Date of chest x-ray: __J__j__ Result: normal__ abnormal_ _

M D Y

Part Ill. Management of Positive TST or IGRA

All students with a positive TST or IGRA with no signs of active disease on chest x-ray should receive a recommendation
to be treated for latent TB with appropriate medication. However, students in the following groups are at increased risk
of progression from LTBI to TB disease and should be prioritized to begin treatment as soon as possible.

• Infected with HIV

• Recently infected with M. tuberculosis (within the past 2 years)
• History of untreated or inadequately treated TB disease, including persons with fibrotic changes on chest
radiograph consistent with prior TB disease
• Receiving immunosuppressive therapy such as tumor necrosis factor-alpha (TNF) antagonists, systemic
corticosteroids equivalent to/greater than 15 mg of prednisone per day, or immunosuppressive drug therapy
following organ transplantation
• Diagnosed with silicosis, diabetes mellitus, chronic renal failure, leukemia, or cancer of the head, neck, or lung
• Have had a gastrectomy or jejunoileal bypass
• Weigh less than 90% of their ideal body weight
• Cigarette smokers and persons who abuse drugs and/or alcohol
• •Populations defined locally as having an increased incidence of disease due to M. tuberculosis, including medically underserved, low-income
populations

___ Student agrees to receive treatment

___ Student declines treatment at this time

Health Care Professional Signature Date

Prepared originally by ACHA's Tuberculosis Guidelines Task Force

Revised by Emerging Public Health Threats and Emergency Response Coalition
Revised further by Erin WilHams, RN, BSN, Dakota College at Bo·tnneau Student Health Services Nurse

Student Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ID# _ _ _ _ _ _ _ _ _ _ Date of Birth_ _ _ __