Tuberculosis (TB) Risk Assessment
Please check any of the risk factors below that apply to you:
Birth, travel, or residence in a country with an elevated TB rate for at least 1 month. YES NO
Includes any country OTHER THAN the United States, Canada, Australia, New Zealand, or a country in
western or northern Europe
Immunosuppression, current or planned. YES NO
HIV infection, organ transplant recipient, treated with medications such as infliximab, etanercept,
steroids (equivalent of prednisone > 15 mg/day for > 1 month) or other immunosuppressive medication
Close contact with someone with INFECTIOUS TB disease during lifetime. YES NO
If the answer is YES to any of the above questions, you must do ONE of the following:
Call the Student Health Center (SHC) at (323) 343-3302 to schedule an appointment to see the nurse for TB clearance as
soon as possible. Please bring this form and any health records such as immunization records, chest x-ray, and blood test to
your appointment. If unsure, please bring the records so the nurse can review them.
Obtain TB clearance from your own private medical provider or community clinic and submit proof of clearance to the SHC.
HOUSING STUDENTS: If you are unable to visit the SHC and require clearance for move-in, the Tuberculosis Verification
form should be completed and submitted to the SHC as soon as possible. The form is available from Housing and Residence
Life, Housing’s website or the SHC’s website.
If the answer is NO to all of the above questions, no further assessment or testing is required. Please submit this form to the
Student Health Center in person, by mail (Cal State L.A. Student Health Center, 5151 State University Drive, Los Angeles, CA 90032),
or by fax at (323) 343-6557.
IMPORTANT: IF THERE IS A CHANGE IN ANY RISK FACTORS LISTED ABOVE,
YOU MUST RETURN TO THE SHC FOR A REPEAT TB RISK ASSESSMENT.
By my signature below: I hereby attest that my answers above are complete and accurate. I agree to return to the SHC for a repeat TB
risk assessment if there are changes in the risk factors listed above.
CHECK IF CLEARANCE IS REQUIRED FOR HOUSING. I am authorizing the Student Health Center to release personal health
information related to my TB clearance to Cal State L.A. Housing and Residence Life.
Print Name: CIN: DOB: ____________ __
Last Name First Name Month / Day / Year
Gender: Male Female
Student’s Signature OR Parent/Guardian’s Signature (if under 18) Date
THIS SECTION FOR SHC PERSONNEL ONLY
TB risk assessment completed.
TB testing done. See visit note.
Patient has a history of positive TB test. See visit note.
Patient has records related to TB clearance (chest x-ray, blood test,
etc.). See patient’s electronic health record.
Comments:
Nurse’s Signature Date
California State University, Los Angeles
STUDENT HEALTH CENTER
TUBERCULOSIS (TB) RISK ASSESSMENT
Forms/Registration/TBRiskAssessment/061919
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