Office of the Registrar - Cape Cod Community College - Student Immunization Records
2240 Iyannough Road, West Barnstable, MA 02668
774-330-4331 / Fax 508-375-4039 / sthompson@capecod.edu
Tuberculosis Non-Symptom Report Questionnaire
This form must be completed annually by a health care provider for all students with a positive
TB Skin Test once a negative x-ray report has been provided.
Name:_______________________________________________ ID #: _____________________________
D/O/B: _________________________________
Telephone/Home: ______________________________ Cell #: ____________________________________
Our records indicate you have previously tested positive on the TB skin test (TST) or are sensitized to the TB
solution. Positive TB skin tests indicate you have been exposed to TB, but do not necessarily indicate you have
active TB disease.
Pre-Placement Annual Post Exposure
I attest that the above information is correct.
Student Signature: _______________________________________________________ Date: _____________
Healthcare Provider Name: _________________________________ Facility: ____________________________
Healthcare Provider Signature: _____________________________________________ Date: _____________
Phone: _______________________________
rev 6/18
NO
YES
1. Have you had recent close contact with someone with infectious TB disease?
2. Have you lived in or traveled in a TB endemic country (e.g. Africa, Asia, Central/ South
America, Caribbean- not Puerto Rico, Eastern Europe, Middle East)?
3. Have you had any of the following signs or symptoms with in the last year?
Unexplained fever
Unexplained cough for 3 weeks or more
If yes, Productive Non-Productive - # of weeks ______
Night sweats
Unexplained weight loss
Chest pain
Unexplained fatigue/malaise
Blood-tinged sputum (Hemoptysis)
4. Have you been informed that you have any condition that could depress your immune
system, such as: cancer, immune deficiency disease, diabetes, silicosis, renal failure,
cirrhosis, HIV infection, poor nutrition, substance abuse, major stomach/intestinal
surgery, severe infectious disease, solid organ transplant?
5. Are you presently being treated with any medication that could depress your immune
system, such as: cortisone, methotrexate, Imuran, chemotherapy, HIV Meds?
6. Is your treating physician aware that you have a positive PPD? (If not, we recommend
that you advise him/her.)
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