Mandatory Tuberculosis Screening Form M4 Medical Students 2015

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Mandatory Tuberculosis Screening Form M4 Medical Students 2015
MANDATORY TUBERCULOSIS SCREENING FORM FOR FOURTH YEAR (M4) FAU MEDICAL STUDENTS 2014-2015
Return completed forms by April 17, 2015 to: FAU Immunization Office, SU-80, Room 114, 777 Glades Road, Boca
Raton, FL 33431 (561) 297-0048 FAX (561) 297-2769
Physician signature is NOT necessary on this form if other official documents are submitted.
Student’s Last name
First Name
MI
Student Z number
Birth date
Gender
Permanent street address
City
State
Zip code
Telephone
REQUIRED SCREENING
1. Tuberculin Skin Test (PPD)
Documentation of a single PPD skin test within 6 months.
PPD in last 6 months
1. ____/____/____ Pos
1a. If you had a positive PPD:
Complete the Tuberculosis Screening Questionnaire and attach
the report from a chest x-ray done within the last 6 months.
If positive PPD, date of most recent CXR:
____/____/____
Neg
Results: Normal____ Abnormal_____
I certify that the information above is true and accurate to the best of my knowledge.
Physician signature: (mandatory)
Physician’s printed name:
Date
Office stamp
required
TUBERCULOSIS SCREENING QUESTIONNAIRE FOR FOURTH YEAR (M4) FAU MEDICAL STUDENTS 2014-2015
Complete this form only if you have a history of a POSITIVE TB skin test.
PERSONAL INFORMATION
Last name
Z number
First name
Date of birth MM/DD/YY
Phone
Email address
Have you ever received BCG?
Yes
No
Date of last PPD skin test:
Did you take any medication associated
with a positive TB test?
___/___/____/
Date of last chest X-Ray:
___/____/____/
Yes
No
Gender
If yes, date of BCG vaccine:
___/___/____/
If yes, dates:_______________________
Check if you are having any of the following unexplained symptoms and they have lasted for 3-4 weeks or longer
Symptom
Unexplained fatigue
Unexplained weight loss
Loss of appetite
Fever (usually at night)
Yes
No
Symptom
Night sweats (drenching)
Persistent cough
Spitting/coughing up blood
Chest pain
Yes
No
HEALTH CARE PROVIDER CERTIFICATION AND ADDRESS
I certify that the information provided above in the section on TB screening is true and accurate to the best of my knowledge.
Physician’s printed name:
An official stamp must appear here for forms and documents to
be approved.
Street Address
Physician’s signature:
City
State
Zip
Date
Attach copy of the x-ray report to this form and return to: FAU Immunization Office, SU-80, Room 114, 777 Glades
Road, Boca Raton, FL 33431 (561) 297-0048 FAX (561) 297-2769