North Central Kansas Technical College
Beloit Campus Hays Campus
P.O. Box 507 | 3033 U.S. Highway 24 | Beloit, Kansas 67420 2205 Wheatland Ave. | Hays, Kansas 67601
1-800-658-4655 | 785-738-2276 1-888-567-4297 | 785-625-2437
PLEASE CHECK YES OR NO TO THE FOLLOWING QUESTIONS:
1. Have you ever had a tuberculosis (TB) test that was positive? YES_____ NO_____
2. Have you ever received the BCG vaccine, which is given outside the United States, to prevent tuberculosis (TB)?
3. Have you been in contact with anyone who was sick with tuberculosis (TB) in the last 3 months?
4. Were you born in a country not on the list below? (Country of birth) ______________________________
5. Have you ever spent more than 3 months in a country not on the list below? YES_____ NO_____
Please list the country _______________________________.
LIST OF EXEMPT COUNTRIES WITH LOW INCIDENCE OF TB
(Defined by the Kansas Department of Health & Environment)
Albania Canada Germany Nauru Sweden
American Samoa Chile Greece Netherlands Switzerland
Andora Costa Rica Grenada New Zealand Turks & Caicos Islands
Antigua & Barbuda Cyprus Hungary Norway United Kingdom of Great
Australia Czech Republic Iceland Saint Kitts & Nevis Britain & North Ireland
Austria Denmark Ireland Saint Lucia United States Virgin Islands
Bahamas Dominica Italy Samoa United States of America
Barbados Fiji Jamaica Slovakia Wallis & Futuna Islands
Belgium Finland Luxembourg Slovenia
British Virgin Islands France Malta Spain
If you answered yes to any of the above questions, you are required to provide documentation of further testing and evaluation by a
health care provider before enrollment of classes at NCK Tech.
1. You will be required to undergo a TB blood test instead of a TB skin test, if you:
* Were born in a country not on the above list.
* Have received the BCG vaccination.
2. If you have had a past positive TB test, you will need to go to a healthcare provider for a signs/symptoms check and complete any
testing required. You will need to present documentation of such to enroll.
3. If you have received prior treatment for any TB disease, you will need to provide proper documentation of treatment protocol and
completion. (Can be obtained from the physician providing care). Submit prior to enrollment.
All tests can be obtained at a County Health Department or your local health care provider before the first day of class.
If you have lived or spent time overseas, list the countries: