TLINGIT & HAIDA HEAD START
Central Council Tlingit and Haida Indian Tribes of Alaska
Mailing: 9097 Glacier Hwy, Juneau, AK 99801• Physical 9095 Glacier Highway • Juneau AK 99801
Phone 907.463.7127 • Toll Free 800.344.1432 • Fax 1.877.389.7796 • www.ccthita-nsn.gov
Tuberculosis Risk Assessments Questionnaire
Date:
Dear Parent/Guardian:
Please complete this TB risk assessment regarding your Head Start student.
TB testing is required if any “YES” boxes are checked
Close contact to someone with infectious TB during the student’s lifetime
Re-testing should only be done in children who previously tested negative and have had new close
contact with an infectious TB case since the last assessment.
Birth, travel or residence in a country with an elevated TB rate for at least 1 month
Includes any country other than the United States, Canada, Australia, New Zealand, or a country
in western or northern Europe
Immunosuppression, current or planned
HIV infection, organ transplant recipient, treated with TNF-alpha antagonist, steroids for more
than 2 weeks (i.e., equivalent of prednisone ≥ 2 mg/kg/day, or ≥ 15mg/day for ≥ 2 weeks), or
other immunosuppressive medication.
□ None of the above apply; TB testing is not required at this time.
Please note:
Do not repeat TB testing unless there are new risk factors since the last negative test.
Children with a newly positive TB test result will be referred to their healthcare provider for a medical evaluation
and parents/guardians will be notified.
Parent/Guardian
Signature
This section to be filled out by Head Start Child Health & Safety Coordinator reviewing this
assessment.
Follow-Up
completed? □
Yes □ No
Mail or fax a copy of physical & screenings to Head Start:
Attention: Child Health & Safety Coordinator
N: Health\Forms\ 13.07 Tuberculosis Risk Assessment Questionnaire Form Rev. 8/212019
