Annual Assessment

Have you EVER spent more than 30 days in a country with an elevated TB rate? This includes all countries except those in Western Europe, Northern Europe, Canada, Australia, and New Zealand.

YesNo

Have you had close contact with anyone who had active TB since your last TB test?

YesNo

Have you ever been diagnosed with active TB disease?

YesNo

Have you ever been diagnosed with latent TB infection or had a positive skin test or a positive blood
test for TB?

YesNo

Have you been treated with medication for TB or for a positive TB test?

YesNo

Do you have a weakened immune system for any reason including organ transplant, recent chemotherapy, poorly controlled diabetes, HIV infection, cancer, or treatment with steroids for more than 1 month, immune-suppressing medications such as a TNF-alpha antagonist or another immunemodulator?

YesNo

Do you smoke?

YesNo

Do you drink alcohol?

YesNo

Do you take drugs that alter your behavior?

YesNo

Do you take prescription medications?

YesNo

I have read the above and declare that I have had no injury, illness or ailment other than as specifically identified. I certify that I am not habituated or addicted to any depressants, stimulants, narcotics, drugs, alcohol or other substances that may alter my behavior.