TUBERCULIN SKIN TESTING QUESTIONNAIRE FOR COLLEGE STUDENTS
Arkansas Department of Health - Tuberculosis Program
Last Name: ____________First Name: __________ MI: ____
Student ID #: _______________Date of Birth: _______Age: ______
Social Security #:____ -___-_____ Enrollment Date: __________
Gender: M F
Race: Hispanic: Y N
Circle: White Black Asian Pacific Islander American Indian Other: ___________
On what date did you enter the US? (mm/dd/yyyy)____________________
In what Country were you born? ______________________________
Are you a permanent resident of the United States? Y N
Are you a US Citizen? Y N
Have you been out of the United States in the last 5 years? Y N
If yes, Most recent year of travel (yyyy): ________Have you ever been to:
Africa Asia South America Eastern Europe Middle East Other:_____
Did you receive a BCG vaccine as a child? Y N Unk
Have you had an HIV test? Y N Date (yyyy): _______ Result? Positive Negative
Have you had a recent TB Skin Test? Y N
If yes, Date applied: _____ Reading: +/- Date Read: _____ Provider:__________ City_______ State___
Have you had a TB Blood Test (IGRA or T-Spot) within the past 3 months? Y N
If yes: Reading (mm): _____ Date (mm/dd/yy): _________ Positive/Negative (circle)
Where did you receive the blood test? Provider:_________________ City:_________ State:__
Most recent chest radiograph (x-ray), if applicable:
Date (mm/dd/yy): __________ Result: _______________
Provider: _________________ Location: _______________
Have you been recommended for and received treatment for latent (inactive) TB? Y N
Provider: __________________ Date treatment started: ______ Date treatment completed:______
Phone Number (cell phone preferred): (____) _________________________
