DEPARTMENT OF HEALTH SERVICES
Division of Public Health
F-02284 (02/2018)
STATE OF WISCONSIN
RECORD OF SCHOOL EMPLOYEE EXAMINATION
Wisconsin State Statute § 118.25(1)(6) on Page 2
Employee Information
Name (First, Middle, Last)
Date of Birth (mm/dd/yyyy)
Street Address, City, State, Zip Code
Results of Tuberculosis Risk Assessment Questionnaire
Use the Wisconsin Tuberculosis (TB) Risk Assessment Questionnaire Screen for Wisconsin Public school Employees, form
number F-02314A.
Do not attach questionnaire to this form.
Practitioners keep a copy of the questionnaire, and record recommendations on this form. Registered nurses and school
nurses will provide a copy of the screening questionnaire to the school board per statute, and if there are tuberculosis risk
factors identified on this screening questionnaire will confidentially recommend further examination by a licensed
practitioner using this form.
The above-named individual completed a tuberculosis risk assessment, and does not have risk factors, or if
tuberculosis risk factors were identified, he/she has been examined and determined to be free of infectious
tuberculosis.
(Practitioner)
The above-named individual completed a tuberculosis risk assessment, and does not have risk factors for
tuberculosis.
SIGNATURE Registered Nurse or School Nurse
The above-named individual is being recommended for further evaluation of tuberculosis by a licensed healthcare
practitioner.
SIGNATURE Registered Nurse or School Nurse
PRACTITIONER’S RECOMMENDATIONS AND CERTIFICATE OF SCHOOL EMPLOYEE EXAMINATION
I, certify, as the examining practitioner, licensed to practice in the State of _______________________________, that I
have examined the above named school employee as required by statute on the following
date,______________________________, and find the above named individual
To be free Not to be free
from tuberculosis in a communicable form at the time of examination on the
basis of the questionnaire and/or examination.
I do I do not
recommend this person as physically suitable for employment. The individual named
herein has been informed of these recommendations.
Name of Examining Practitioner
SIGNATUREExamining Practitioner
Date Signed
Return completed form to the appropriate school district.
118.25 Health examinations. (1) In this section:
(a) “Practitioner” means a person licensed as a physician or as
a physician assistant in any state or licensed or certified as an
advanced practice nurse prescriber in any state. In this paragraph,
“physician” has the meaning given in s. 448.01 (5).
(b) “School employee” means a person employed by a school
board who comes in contact with children or who handles or pre-
pares food for children while they are under the supervision of
school authorities.
(2) (a) 1. Subject to par. (b), a school board shall, as a condi-
tion of employment, require a physical examination of every
school employee of the school district. The school board shall
ensure that the physical examination includes a screening ques-
tionnaire for tuberculosis approved by the department of health
services and, if indicated, a test to determine the presence or
absence of tuberculosis in a communicable form. Freedom from
tuberculosis in a communicable form is a condition of employ-
ment. The school employee shall be examined by a practitioner
in the employ of or under contract with the school district, but if
a practitioner is not employed or under contract, the examination
shall be made by a practitioner selected by the school employee.
2. The school board may require a school employee to com-
plete additional health examinations, including physical examina-
tions and an examination consisting of a screening questionnaire
for tuberculosis approved by the department of health services, at
intervals determined by the school board. A screening question-
naire administered as permitted under this subdivision may be
administered by a school nurse or by a registered nurse selected
by the school employee and licensed under s. 441.06 or in a party
state, as defined in s. 441.50 (2) (j).
(b) The school board may not require physical examinations
of any school employee who files with the school board an affida-
vit setting forth that the employee depends exclusively upon
prayer or spiritual means for healing in accordance with the teach-
ings of a bona fide religious sect, denomination, or organization
and that the employee is to the best of the employee’s knowledge
and belief in good health and that the employee claims exemption
from health examination on these grounds. Notwithstanding the
filing of such affidavit, if there is reasonable cause to believe that
such employee is suffering from an illness detrimental to the
health of the pupils, the school board may require a health exami-
nation of such school employee sufficient to indicate whether
or
not such school employee is suffering from such an illness. No
school employee may be discriminated against by reason of the
employee’
s filing such affidavit.
(c) 1. A practitioner performing a physical examination under
par. (a) shall complete a report of the examination upon a standard
form prepared by the department of health services. The practi-
tioner shall retain a copy of the report in his or her files and shall
make confidential recommendations therefrom to the school
board and to the school employee on
a form prepared by the
department of health services. The recommendation form shall
contain space for a certificate that the person examined by the
practitioner appears to be free from tuberculosis in a communica-
ble form.
2. A registered nurse or school nurse administering a screen-
ing questionnaire under par.
(a) 2. shall provide a copy of the
screening questionnaire to the school board and shall make confi-
dential recommendations therefrom to the school board and to the
school employee on a form prepared by the department of health
services. The screening questionnaire shall contain space for a
certificate that the person examined by the registered nurse or
school nurse does not have risk factors for tuberculosis. If tuber-
culosis risk factors are identified on the screening questionnaire,
the registered nurse or school nurse shall recommend that the per-
son receive a test from a practitioner to determine the presence or
absence of tuberculosis in a communicable form. If a test to deter-
mine the presence or absence of tuberculosis in a communicable
form is recommended of the person, and if the test indicates the
absence of tuberculosis in a communicable form, the practitioner
who administers the test shall certify, on a form prepared by the
department of health services, that the person appears to be free
from tuberculosis in a communicable form.
3. The school board shall pay the cost of the examinations
required under par. (a), including X−rays and tuberculin tests if
needed, out of school district funds.
(3) In counties having a population of less than 500,000, the
school board may require periodic health examinations of pupils
by physicians, under the supervision of local health departments
and the department of health services, and may pay the cost of the
examinations out of school district funds.
(4) If a health or physical examination made under this section
includes the testing of vision, such test may be made by an
optom-etrist. Forms used for reporting such vision tests shall
so indicate.
(5) As a condition of employment, special teachers, school
psychologists, school social workers, cooperative educational
service agency personnel and other personnel working in
public schools shall have physical examinations under sub. (2).
The employing school district or agency shall pay the cost of
such examinations.
(6) As a condition of employment, employees of the state
superintendent whose work brings them into contact with
school children or with school employees shall have physical
examina-tions under sub. (2).
History: 1979 c. 221, 301; 1993 a. 27, 492; 1995 a. 27 ss. 9126
(19), 9145 (1); 1997 a. 27; 2007 a. 20 s. 9121 (6) (a); 2017 a.
107; s. 35.17 correction in (2) (c) 2.
Updated 2015−16 Wis. Stats. Published and certified under s. 35.18. January 22, 2018.