Incarnate Word Academy
2021-22 TB Questionnaire
Name of child:
Date of Birth:
Organization administering questionnaire Incarnate Word Academy
Tuberculosis (TB) is a disease caused by TB germs and is usually transmitted by an adult person with active TB lung disease. It is
spread to another person by coughing or sneezing TB germs into the air. These germs may be breathed in by a person.
Adults who have active TB disease usually have many of the following symptoms: cough for more than two weeks duration, loss of
appetite, weight loss of ten or more pounds over a short period of time, fever, chills and night sweats.
A person can have TB germs in his or her body but not have active TB disease (this is called latent TB infection or LTBI).
Tuberculosis is preventable and treatable. TB skin testing (often called the PPD or Mantoux test) is used to see if you have been
infected with TB germs. NO vaccine is recommended for use in the United States to prevent tuberculosis. The skin test is not a
vaccination against TB.
We need your help to find out if you have been exposed to tuberculosis. All information obtained herein will be kept in strict
Place a mark under the appropriate box:
TB can cause fever of long duration, unexplained weight loss, a bad cough (lasting
over two weeks), or coughing up blood. As far as you know:
Has your child been around anyone with any of these symptoms or problems? Or
Has your child had any of these symptoms or problems? Or
Has your child been around anyone sick with TB?
Was your child born in or has your child traveled in the past year to Mexico or any
other country in Latin America, the Caribbean, Africa, Eastern Europe or Asia for
longer than 3 weeks?
If so specify which country/countries?_______________________________
To your knowledge, has your child spent time (longer than 3 weeks) with anyone who
is/has been an intravenous (IV) drug user, HIV-infected, in jail or prison or recently
came to the United States from another country?
Has your child ever been tested for TB?
Yes____ (if yes, specify date:___________) No____
was seen on
Name Date
For Physician use only - (Must be a practicing physician/provider in the state of Texas per Texas Department of State Health Services guidelines)
This form may be signed in counterparts and may be delivered by facsimile or other electronic means, each of which may
be deemed an original, and all of which together constitute one and the same agreement.
Has your child ever had a positive skin test?
Yes____ (if yes, specify date: __________) No____
PPD administered No___ Yes___ If YES:____________________________________________________________
Date administered: ______/_____/______ Date Read: ______/_____/______ Result of PPD test: _________mm response
PPD Provider Signature Printed Name
Type of service provider (i.e. school, Health Steps, other clinics)________________________________________________________
If positive, referral to physicain No____ Yes____ If yes, name of provider_______________________________________________