Texas Woman's University
Tuberculosis (TB) Screening Requirement Form for New Students
Tuberculosis (TB) screening is required for all incoming International students (including newly transferred) and those
considered to be International by TAC §21.25(c) (formerly, HB 1403) or TEC 54.052 who were born in, resided in, or traveled to a
country other than the United States. Students must complete and sign the following questionnaire. For help completing this
form, please contact TWU Student Health Services at 940.898.3825 or visit us on the TWU Denton campus.
Student Name
TWU ID No.
Date of Birth
In the lists below, please check the boxes to the left of ALL countries you have traveled to and/or resided in.
South Africa
South Sudan
Sri Lanka
Sudan
Suriname
Swaziland
Syrian Arab Republic
Tajikistan
Tanzania (United Rep. of)
Taiwan
Thailand
Timor-Leste
Togo
Tunisia
Turkmenistan
Tuvalu
Uganda
Ukraine
Uruguay
Uzbekistan
Vanuatu
Venezuela (Bolivarian Rep. of)
Viet Nam
Yemen
Zambia
Zimbabwe
Afghanistan
Algeria
Angola
Anguilla
Argentina
Armenia
Azerbaijan
Bangladesh
Belarus
Belize
Benin
Bhutan
Bolivia (Plurinational State of)
Bosnia and Herzegovina
Botswana
Brazil
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Central African Republic
Chad
China
China, Hong Kong SAR
China, Macao SAR
Colombia
Comoros
Congo
Côte d'Ivoire
Dem. People's Rep. of Korea
Dem. Rep. of the Congo
Djibouti
Dominican Republic
Ecuador
El Salvador
Equatorial Guinea
Eritrea
Ethiopia
Fiji
Gabon
Gambia
Georgia
Ghana
Greenland
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
India
Indonesia
Iraq
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Dem. Rep.
Latvia
Lesotho
Liberia
Libya
Lithuania
Madagascar
Malawi
Malaysia
Maldives
Mali
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia (Fed. States of)
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
New Caledonia
Nicaragua
Niger
Nigeria
Northern Mariana Islands
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Portugal
Qatar
Republic of Korea
Republic of Moldova
Romania
Russian Federation
Rwanda
Sao Tome and Principe
Senegal
Serbia
Sierra Leone
Singapore
Solomon Islands
Somalia
Is your country of birth listed below? Yes No
If yes, which of these is your birth country?
Source: World Health Organization Global Health Observatory, Tuberculosis Incidence 2015. Countries with incidence rates of ≥ 20 cases per 100,000 population. For future updates, refer to http://
www.who.int/tb/country/en/.
Yes No
Yes No
Yes No
1. Did you select any of the countries above?
2. Have you ever had a BCG vaccine (Bacillis Calmette-Guerin)?
3. Have you ever had a positive TB test or been diagnosed with TB?
4. Have you had close contact with persons known or suspected to have TB?
5. Have you been a volunteer or health care worker who served clients in a hospital or healthcare facility?
6. Have you been a volunteer, employee or resident in a correctional facility, long-term facility or homeless shelter?
Yes No
Students answering NO to every question submit only this completed form.
Any YES answer requires TB Blood Testing using T-Spot or QuantiFERON Gold; TB Skin Testing is NOT accepted.
See next page for information for students with positive TB Blood Tests results or history of antibiotics for TB infection.
I have completed the above questionnaire. I have not come from an area with high incidence of TB and I verify that all answers to the above questions are NO.
I have completed the above questionnaire and submit my TB Blood Test results. Please note that if TB test result is positive, a Chest X-Ray and Tuberculosis
Clearance Statement is required in order to be considered compliant and register for classes.
I have completed the above questionnaire. I have taken antibiotics for TB infection and do not require a TB Blood Test. Submission of a recent Chest X-Ray,
Tuberculosis Clearance Statement, and proof of antibiotic treatment is required in order be considered compliant and register for classes.
Please refer to the TWU Student Tuberculosis Screening and Case Management Policy for additional information. For questions, please call TWU Student Health Services at 940.898.3825 or visit TWU
SHS website https://www.twu.edu/student-health-services/tuberculosis-screening/
Submit signed and completed form to immunization@twu.edu.
Student Signature
Date
Yes
No
Yes No
Select country of birth
click to sign
signature
click to edit
2
TWU Student Tuberculosis Screening and Case Management Policy Requirements
New International Students and those considered to be international by TAC §21.25(c) (formerly, HB 1403)
or TEC 54.052 due to birth or residence outside of the U.S.
Must complete the TB screening process prior to the first day of class.
Must submit the TWU Tuberculosis (TB) Screening Requirement Form for New Students
o Individuals who answer YES to any risk factor for TB are required to have a TB Blood Test
o Individuals born, resided in, or traveled to countries at low risk for TB who also answer NO
to all risk factor questions submit only the completed Form (TB Blood Test not required)
Tuberculin Skin Testing is NOT accepted for screening for these students
Tuberculosis Testing Procedure for those answering YES to any question on the Screening Form
TB Blood Testing using T-Spot or QuantiFERON Gold required
o Testing must be done in the United States within 365 days prior to the first day of classes
upon entrance into TWU
o Acceptable sites for TB screening include TWU Student Health Services, TWU
subcontracted health clinics in Dallas and Houston, US licensed private physicians, and US
licensed medical clinics
o Students who have previously taken antibiotics for TB do not need a TB Blood Test, see
below for alternate requirements
Students with negative TB Blood Test results submit test results with Form; no additional testing
required
All students with positive TB blood test results must submit BOTH of the following:
o Chest x-ray results from x-ray obtained in the U.S. within 365 days prior to the first day of
classes upon entrance to TWU
o Completed Tuberculosis Clearance Statement signed by a U.S. licensed medical professional
Students treated with antibiotics for TB infection (active or latent) in the past must submit ALL of
the following:
o Chest x-ray results from x-ray obtained in the U.S. within 365 days prior to the first day of
classes upon entrance to TWU
o Proof of antibiotic treatment, including duration of therapy
o Completed Tuberculosis Clearance Statement signed by a U.S. licensed medical professional
o New TB blood testing is not required
Chest x-ray submission requires the following to meet compliance requirements
o Positive TB Blood Test results AND/OR proof of antibiotic treatment for TB with duration
of therapy
o Completed Tuberculosis Clearance Statement signed by U.S. licensed medical professional
o Chest x-ray and Statement without test results or proof of antibiotics is NOT accepted
Non-compliance with this policy will prevent students from registering for classes.
Please refer to the TWU Student Tuberculosis Screening and Case Management Policy f
or additional
information.
For questions, please call TWU Student Health Services at 940.898.3825 or visit TWU SHS website
https://www.twu.edu/student-health-services/tuberculosis-screening/
Submit form by fax (940) 898-3849, mail to TWU Student Health Services Immunization Compliance Specialist P.O. Box 425467
Denton, TX 76204-5467, fax (940) 898-3849 or hand deliver to Student Health Service on the TWU Denton Campus