A. Check all that apply


  • Traveled to or have lived outside of the United States over the summer.
  • Have recently been diagnosed with a chronic medical condition that may impair your immune system.
  • Worked or volunteered in a health care setting, correctional facility, or homeless shelter over the summer.
  • Contact with a person known to have active tuberculosis.
  • Completed medication therapy for Latent Tuberculosis. (A chest x-ray is required after medication therapy only if one of the other criteria is met. No tuberculin skin test should be placed.)
  • None of the above apply.

B. Tuberculosis Disease Symptoms.

If you meet one or more of the criteria listed above, please check any symptoms that apply.


  • Chest Pain
  • Unexplained Fever
  • Night Sweats
  • Coughing up Blood
  • Loss of Appetite
  • Cough > 3 Weeks
  • Chills
  • Weakness
  • Fatigue
  • Productive cough (coughing something up)
  • Respiratory difficulty (shortness of breath)
  • Unexplained Weight Loss

I certify that the above information is true and correct to the best of my knowledge.