COVID and TB Screening

COVID-19 and TB Symptoms Screening

First Name(Required)

Last Name(Required)

Phone Number(Required)

Email(Required)

COVID Screening

Part I: COVID Symptoms Screening

Have you or anyone in your household had a fever of 100.4 or higher during the past two weeks?(Required)

Includes anyone you associate with on a regular basis (examples: your colleagues at work and/or friend/s)

Have you or anyone in your household had a cough or unusual shortness of breath during the past two weeks?(Required)

includes anyone you associate with on a regular basis (examples: your colleagues at work and/or friend/s)

Have you or anyone in your household tested for COVID-19 during the past two weeks?(Required)

includes anyone you associate with on a regular basis (examples: your colleagues at work and/or friend/s)

Have you or anyone in your household traveled to a region/country considered high risk exposure to COVID-19 in the past two weeks?(Required)

includes anyone you associate with on a regular basis (examples: your colleagues at work and/or friend/s)

More info, please review

https://wwwnc.cdc.gov/travel/noticescovid19

Has anyone in your household been exposed to anyone who has tested positive for COVID-19 in the past two weeks?(Required)

Includes anyone you associate with on a regular basis (examples: your colleagues at work and/or friend/s)

Have you received the COVID vaccine?(Required)

How many doses of the COVID vaccine have you received?(Required)

TB Screening

Part I – TB Risk Screening

Have you ever had close contact with someone who was sick with active TB disease?(Required)

Were you born in, or have you traveled for more than one month to, any country where TB is common (e.g., Africa, Asia, Eastern Europe, Latin America, or the Middle East)?(Required)

Have you ever lived, worked, or volunteered in settings where TB is more likely to spread (e.g., hospitals, long-term care facilities, prisons, shelters)?(Required)

Do you have a weakened immune system (e.g., HIV infection, organ transplant, taking immunosuppressive medications such as prednisone, TNF-alpha inhibitors, chemotherapy)?(Required)

Have you ever had a positive TB skin test (TST) or TB blood test (IGRA)?(Required)

Have you ever been treated for latent or active TB disease?(Required)