Tuberculosis Form

Have you ever had close contact with persons known or suspected to have active TUBERCULOSIS (TB) disease?

Yes

No

Were you born in one of the countries or territories listed below that have a high incidence of active TB disease? Click HERE to view list of countries/territories.

Yes

No

If you answered 'YES' to the above question, please select the countries or territories from the drop-down prompt?

Have you had frequent or prolonged visits to one or more of the countries or territories in the previous question with a high prevalence of TB disease? Click HERE to view list of countries/territories.

Yes

No

If you answered 'YES' to the above question, please select the countries or territories from the drop-down prompt? (Press CTRL or Command to select multiple countries)

Have you been a resident and/or employee of high-risk congregate settings (e.g., correctional facilities, long-term care facilities, and homeless shelters)?

Yes

No

Have you been a volunteer or health care worker who served clients who are at increased risk for active TB disease?

Yes

No

Have you ever been a member of any of the following groups that may have an increased incidence of latent M. tuberculosis infection or active TB disease: medically underserved, low-income, or abusing drugs or alcohol?

Yes

No