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TUBERCULOSIS SCREENING QUESTIONNAIRE
(To be completed by all students before class attendance at Garden City Community College)
Name: ____________________________________ _______________ _______________ ____________________
PLEASE PRINT: Last Name/First Name & MI DOB: (mm/dd/year) Student ID # Phone Number
LIST OF EXEMPT COUNTRIES WITH LOW INCIDENCE OF TB
(Defined by the Kansas Department of Health & Environment)
Albania Canada Germany Nauru Spain
American Samoa Chile Greece Netherlands Sweden
Andora Costa Rica Grenada New Zealand Switzerland
Antigua & Barbuda Cyprus Hungary Norway Turks & Caicos Islands
Australia Czech Republic Iceland Saint Kitts & Nevis United Kingdom of Great
Austria Denmark Ireland Saint Lucia Britain & North Ireland
Bahamas Dominica Italy Samoa United States Virgin Islands
Barbados Fiji Jamaica Slovakia United States of America
Belgium Finland Luxembourg Slovenia Wallis & Futuna Islands
British Virgin Islands France Malta
If none of the above applies, please sign below and return to the Registrar for enrollment at GCCC.
To the best of my knowledge, the information provided above is accurate and complete. I am aware that misrepresentation of information could
result in dismissal from GCCC and may jeopardize my health. I agree to comply with any and all requirements relating to Kansas Statue KSA 2009,
Supp. 65-129.
By signing this form, I agree for communication to occur between GCCC and other health care personnel related to my medical care regarding TB Risk
Assessment and it requirements for enrollment.
Student Signature_____________________________________________________________Date___________________________
ABOUT THIS FORM:
Tuberculosis, also known as TB, is a bacterial infection that attacks the lungs and sometimes other parts of the body. It is spread when
someone infected with the disease coughs, sneezes, laughs or sings and the bacteria is inhaled by someone nearby.
Garden City Community College requires ALL students to complete a Tuberculosis Screening Questionnaire, per Kansas Statute KSA 2009
Supp. 65-129 to aid in prevention and control of Tuberculosis as required by State of Kansas Department of Health & Environment.
If further testing is indicated, the process could be lengthy. Begin the process ASAP to avoid being unable to enroll in your
preferred classes. For additional information on TB: www.cdc.gov/tb/publications/factsheets/default.htm
IF YOU ANSWERED YES TO ANY OF THE ABOVE QUESTIONS, YOU ARE REQUIRED TO PROVIDE DOCUMENTATION OF TESTING AND
EVALUATION BY A HEALTH CARE PROVIDER BEFORE ENROLLMENT OF CLASSES AT GCCC. (See GCCC Certificate of Health form)
1. You will be required to undergo a Tuberculosis skin or blood test. (Documentation of a negative TB test obtained in the United
States in the past year will be accepted at GCCC. Proper documentation will include a copy of the (mantoux/PPD) skin test
with results documented in millimeters, signed and dated by health care provider and attached to the Certificate of Health form.)
2. If you have a past positive TB test with history of latent infection, you will need to present documentation (written
Interpretation of your last chest x-ray obtained in the United States AND copies of all medical and treatment outcomes to
GCCC Student Health Services. You will be required to complete a yearly signs/symptoms review at GCCC Student Health
Services, while enrolled at GCCC, with a referral for chest x-ray if indicated.
3. If you have a history of active TB disease, you will be required to submit previous treatment and outcome medical records,
signed and documented by your health care provider to GCCC Student Health Services. This will include the written
interpretation of a chest x-ray received in the United States. You will also be required to complete yearly signs/symptoms
review at GCCC Student Health Services while enrolled at GCCC, with referral for a chest x-ray, if indicated.
PLEASE CIRCLE 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)?................ YES NO
(This vaccine is usually given in countries of High Incidence for TB.)
3. Have you been in contact with anyone who was sick with tuberculosis (TB) in the last 3 months? ........................................ YES NO
4. Were you born in a country not on the list below? (Country of birth) ______________________________.….…..………… YES NO
(If you were born in the United States, the answer is NO.)
5. Have you ever spent more than 3 months in a country not on the list below? ……………..……………………………………. YES NO
Please list the country _______________________________.
