Revised January 2021 Archdiocese of Galveston-Houston | Catholic Schools Office, 2021-2022 58d
TB QUESTIONNAIRE: STUDENTS
Catholic Schools Office
2021-2022 School Year
Archdiocese of Galveston-Houston
Name of Child: Date of Birth:
School: Date:
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 the child. Children 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 your child has 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 your child has been exposed to tuberculosis.
All information obtained herein will be kept in confidence
Place a mark in 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 Mexico or any other country in Latin America, the Caribbean,
Africa, Eastern Europe or Asia?
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 been tested for TB? Yes___ (if yes, specify date ____/____) No___
Has your child ever had a positive TB skin test? Yes___ (if yes, specify date ____/____) No___
Parent signature Date
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For Physician use only- (Must be a practicing physician/provider in the state of Texas per Texas Department of State Health Services guidelines)
PPD administered No___ Yes___ If YES:
Date administered: _____/_____/______ Date read: ______/______/_______ Result of PPD test: __________ mm response
PPD provider signature printed name
City: County:
Type of service provider (i.e. school, Health Steps, other clinics)
If positive, referral to physician No____ Yes____ If yes, name of provider:
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