Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 2Employee Name *FirstLastDo you currently have any of the following that has lasted three (3) weeks or longer? LayoutUnexplained productive cough? *YesNoUnexplained appetite loss? *YesNoNight sweats? *YesNoChest pain? *YesNoBloody sputum? *YesNoUnexplained weight loss? *YesNoUnexplained fever? *YesNoShortness of breath? *YesNoIncreased fatigue? *YesNoHave you ever: LayoutEver been told you have TB? *YesNoHad a positive TB skin test? *YesNoDate of last negative PPD skin test result: *Lived with anyone with TB? *YesNoHad a BCG vaccination? *YesNoLayoutSignatureClear SignatureDate *Employer Review: If the employee answers yes to any question 1-9, document the objective reason for the symptom. If there is no known reason for the symptom lasting 3 weeks or longer, the employee is to have a TB skin test. If the employee answers yes to any question A-B, the employee is to have a TB skin test. If the employee answers yes to question C, the employee is to have either a chest x-ray or a physician statement noting the employee is free from communicable disease. The following apply to this employee:123NoneNextUpdating preview…This is a preview of your submission. It has not been submitted yet! Please take a moment to verify your information. You can also go back to make changes.PreviousSubmit
