Homepage Fill Out Your Fill In The Blanks On Tuberculosis Form
Article Structure

Completing the Fill In The Blanks On Tuberculosis form is an essential step in maintaining a safe and healthy workplace. This form is primarily used for Tuberculosis Skin Test (TST) screening, which is vital for identifying individuals who may be at risk of having or developing tuberculosis. Key sections of the form include personal information such as your name, department, and position, as well as important health questions. These questions inquire about previous positive TST results, recent vaccinations, and potential chronic health conditions. The form stipulates that it is your responsibility to have the TST read by a licensed healthcare professional within 48-72 hours, ensuring that results are documented correctly. Additionally, it outlines the circumstances under which annual testing is required, such as new employment, annual reviews, and exposure scenarios. Following the completion of the form, you must sign to confirm understanding of the instructions provided, acknowledging the importance of keeping a copy for your records. Your health and safety are paramount, and this screening process helps to safeguard both you and your colleagues.

Fill In The Blanks On Tuberculosis Example

EMPLOYEE HEALTH SERVICES

57 Bee Street – MSC 213

Charleston, SC 29425-2130

TUBERCULOSIS SKIN TEST (TST) SCREENING

Telephone

(843) 792-2991

 

Fax

(843) 792-1200

 

REASON:

 

EMPLOYER:

 

Pre-Placement

1st Step 2nd Step

MUHA (Hospital)

Crothall

Annual

 

MUSC (University)

Sodexho

Annual Past Positive Screening

UMA/CFC

Other________________

Exposure Baseline (with ACORD)

Volunteer

 

Post Exposure (10 week with ACORD)

Last Name____________________ First_______________ MI____ Birth date____/____/____ Emp ID_______________

Dept___________________ Position____________________ Work #_________________ Home #_________________

Address______________________________________ City____________________ State_____ Zip Code___________

Have you ever had a positive TST? ฀ YES ฀ NO If yes, when?________________________________________

Have you received a live vaccine within the past 30 days? ฀ YES ฀ NO

If yes, what vaccine? Measles, Mumps, Rubella (MMR) Varicella (Chickenpox) Other___________________

Are you immune compromised or are you taking any immunosuppressant medications? ฀ YES ฀ NO

Do you currently have any of the following chronic conditions?

YES / NO

YES / NO

YES / NO

Chronic cough (>3 weeks)

Cough up sputum or blood

Poor appetite

Chronic fatigue (>3 weeks)

Shortness of breath

Recurrent infections

Chronic chest discomfort

Unexpected weight loss

 

 

Persistent low grade fever

Night Sweats (excluding menopause)

 

Annual TST is performed to meet DHEC, OSHA, and JCAHO requirements.

It is YOUR responsibility to have your TST read by a licensed person (MD, RN, LPN, RT) within 48-72 hours and return proof to EHS. You may not read your own TST.

Your TST may show erythema (flat redness) or induration (hardened, raised area). If your skin test shows induration, it must be read by Employee Health Services.

I have read and understand the above instructions. I also understand that I will be given one copy of this form free of charge; hereafter there will be a charge for copies. I understand that I am advised to keep a copy of this form to avoid future charges.

Signature________________________________________________________________ Date____________________

LICENSED PERSONNEL PLEASE COMPLETE THIS SECTION

PLACED: Date__________ Time__________AM / PM LA / RA MFT/Lot #__________ Exp Date__________

By (Print Name)_________________________ (Title)__________ (Signature)___________________________________

(DO NOT cover injection site with band-aid or adhesive tape as some employees may have a reaction to the adhesive.)

READ: Date____________

Time__________AM / PM Results: Induration _______mm Erythema _______mm

By (Print Name)_________________________ (Title)__________ (Signature)___________________________________

Return to EHS for 2nd Step TST:

Within 7-30 days After 30 days Not applicable

 

Copy given to Employee, Date____________

Form Characteristics

Fact Name Description
Location The form is from Employee Health Services located at 57 Bee Street – MSC 213, Charleston, SC 29425-2130.
Contact Information The phone number for inquiries is (843) 792-2991 and the fax number is (843) 792-1200.
Purpose of Screening The tuberculosis skin test (TST) screening is done for several reasons, including pre-placement and annual testing.
Immunocompromised Status Respondents must indicate if they are immune compromised or taking immunosuppressant medications.
Completion Responsibility Individuals are responsible for having their TST read by licensed personnel within 48-72 hours after the test.
Indication of Reaction If the TST shows induration, it requires further evaluation by Employee Health Services.
Document Retention Participants are advised to keep a copy of the form to avoid future charges for additional copies.
Governing Laws This screening meets the requirements set by DHEC (Department of Health and Environmental Control), OSHA (Occupational Safety and Health Administration), and JCAHO (Joint Commission on Accreditation of Healthcare Organizations).

Guidelines on Utilizing Fill In The Blanks On Tuberculosis

Filling out the Tuberculosis form is an important step in ensuring your health and safety at the workplace. The form is straightforward, but it requires careful attention to detail. Below are step-by-step instructions to help you complete the form accurately.

  1. Obtain the form. Make sure you have the correct version of the Tuberculosis form.
  2. Fill in your personal information. Start by writing your last name, first name, and middle initial. Include your birth date, employee ID, department, position, work phone number, home phone number, and your complete address, including city, state, and zip code.
  3. Select the reason for the screening. Choose one or multiple reasons from the provided options, such as Pre-Placement or Annual. If you select "Other," specify the reason in the blank space provided.
  4. Answer the TST history questions. Indicate whether you have ever had a positive TST by selecting YES or NO. If YES, provide the date of your last positive test.
  5. Review and complete the vaccine history. If you have received a live vaccine within the past 30 days, select YES and indicate which vaccine you received.
  6. Indicate any health conditions. Answer whether you are immune compromised or on immunosuppressant medications. Next, check YES or NO for each chronic condition listed.
  7. Read the instructions carefully. Understand the guidelines regarding the reading of your TST results, including the importance of having it read by a licensed professional within 48-72 hours.
  8. Sign and date the form. Acknowledge your understanding of the instructions by providing your signature and the date of completion.
  9. Leave the licensed personnel section for the professional. Licensed personnel will fill out details related to the placement, reading of the test, and results.

After completing these steps, ensure everything is legibly filled out before submitting the form as required. Keeping a copy of your completed form is advisable, as it can prevent additional charges for duplicates in the future.

What You Should Know About This Form

What is the purpose of the Fill In The Blanks On Tuberculosis form?

This form is designed to gather essential information for tuberculosis (TB) skin test screenings. Employers require this information to comply with public health regulations and ensure the safety of employees and the community. The information collected helps in monitoring potential exposure and preventing the spread of TB in the workplace.

Who needs to fill out this form?

The form is typically filled out by employees who are required to undergo TB testing as part of their pre-employment process, annual screenings, or after potential exposure to TB. Employers such as hospitals, universities, and other organizations involved in healthcare often mandate this screening.

What should I do if I have previously tested positive for a TB skin test?

If you have a history of a positive TB skin test, it is important to indicate this on the form. You should also provide the date of your last positive test. This information may be used to guide your subsequent evaluations and any necessary follow-up actions. Additionally, consider discussing your history with the medical personnel conducting the test.

How long do I have to get my TB skin test read?

You must have your TB skin test read by a licensed healthcare professional within 48 to 72 hours after the test is administered. It is crucial to adhere to this timeframe to ensure accurate results. If you do not have it read within this period, you may need to repeat the test.

What happens if I do not keep a copy of the form?

If you do not keep a copy of the form, you may incur charges for replacements in the future. It is your responsibility to retain a copy as proof of the screening for your records. Keeping a copy can help prevent delays or issues with your employment verification related to TB testing.

Can I read my own TB skin test result?

No, you cannot personally read the TB skin test result. The results must be evaluated by a licensed healthcare professional, such as a doctor, registered nurse, licensed practical nurse, or respiratory therapist. This guideline is in place to ensure an objective and accurate assessment of the test results.

What symptoms should I be aware of that may require further evaluation?

You should be attentive to symptoms such as a chronic cough lasting more than three weeks, coughing up sputum or blood, poor appetite, unexplained weight loss, or persistent low-grade fever. If you experience any of these symptoms, it's vital to inform the healthcare provider or your employer to assess the need for further evaluation.

What do I need to do after receiving a live vaccine?

If you have received a live vaccine within the past 30 days, you should indicate this on the form and specify the type of vaccine. This information is important as it may temporarily affect your immune response and the accuracy of the TB test. Always consult with your healthcare provider about the appropriate timing of vaccinations in relation to TB testing.

Common mistakes

Filling out the Tuberculosis Skin Test (TST) screening form requires careful attention to detail. One common mistake is failing to provide accurate personal information. Employees sometimes leave sections, such as the name, birth date, or contact details, incomplete. These errors can lead to delays in processing and could affect healthcare protocols.

Another frequent error involves selecting the wrong reason for the test. A thorough review of the options is essential to ensure that the reasoning aligns with the employee's needs. Incorrect choices may lead to inappropriate testing procedures, which can complicate further healthcare assessments.

Many individuals overlook the question regarding a past positive TST result. Providing a clear answer is crucial. A "yes" response needs a specific date, and forgetting to include this information can create additional complications in medical evaluations. Missing this important detail means that the healthcare provider cannot accurately assess the individual's risk for tuberculosis.

Inappropriately answering questions about recent vaccinations is another mistake. The form asks whether a live vaccine was received in the last 30 days. Individuals sometimes answer "no" without considering all vaccinations received. This oversight can lead to inaccuracies in interpreting the TST results and the employee's overall health.

When addressing health conditions, clarity is vital. Marking "yes" or "no" to chronic conditions should be approached thoughtfully. Failing to disclose chronic cough or unexpected weight loss, for example, can hinder appropriate medical evaluations, leading to potential health risks.

Compliance with the reading timeline is not always understood. Employees may fail to return for their TST to be read within the specified 48-72 hours. Ignoring this timeline can result in needing to undergo the test again, causing further delays and unnecessary expenses.

The signature and date at the end of the form are crucial. Some individuals neglect to sign or date, potentially invalidating the screening process. This action can also result in administrative issues that delay necessary health services.

Additionally, misunderstanding the instructions given to licensed personnel is a concern. Those completing the bottom section require clear adherence to procedures. Any mistakes in documenting the results can create confusion for the employee's health record, leading to complications in their care.

Another pitfall occurs when the form is not reviewed before submission. Employees may rush, overlooking inconsistencies or mistakes. Taking a moment to double-check the form can prevent errors that might lead to further evaluation or delays.

Finally, ignoring the importance of keeping a personal copy of the form creates future complications. Employees should ensure they retain documentation for their records to avoid additional charges for obtaining copies later. Properly managing this information supports ongoing health management and ensures access to vital health records.

Documents used along the form

When dealing with tuberculosis screening and testing, several other forms and documents may also be required. These documents facilitate proper health management and compliance with workplace regulations. Here is a list of forms commonly used alongside the Fill In The Blanks On Tuberculosis form.

  • Health History Questionnaire: This form collects an individual’s medical history and relevant health information, which is essential for screening and treatment decisions.
  • Employee Immunization Record: This documentation tracks an employee’s vaccinations, such as tuberculosis, measles, and seasonal flu, ensuring compliance with workplace health policies.
  • Tuberculosis Exposure Risk Assessment: This form helps evaluate an employee's risk of exposure to tuberculosis, guiding necessary precautionary measures and follow-up actions.
  • Tuberculosis Treatment Consent Form: This document secures patient consent for treatment procedures related to tuberculosis, outlining the risks and benefits associated with the treatment.
  • Return to Work Authorization: Employers often require this form to confirm that an employee has met the necessary health criteria to return to work after a tuberculosis diagnosis.
  • OSHA Recordkeeping Form: This record helps employers comply with Occupational Safety and Health Administration requirements regarding the reporting of work-related health conditions, including tuberculosis.
  • Health Tracking Log: This ongoing document tracks health screening and test results over time, promoting transparency and facilitating regular assessments.
  • Immunization Exemption Form: Employees may use this form to declare exemptions from immunization requirements for religious or medical reasons, providing necessary alternatives in health policies.
  • Contact Tracing Form: In case of exposure, this document enables tracking of individuals who may have been in contact with an infected person, assisting public health investigations.
  • Workplace Safety Training Record: This form documents safety training related to communicable diseases, including tuberculosis, ensuring all employees understand workplace health protocols.

Utilizing these additional forms contributes to effective health management and encourages a safer work environment. Make certain that each document is filled out accurately and submitted as required to maintain compliance with health standards.

Similar forms

  • Health Screening Form: Similar to the Tuberculosis form, this document requests personal information and health history to assess potential health risks for employment.
  • Vaccination Record: This record tracks vaccinations an individual has received, similar to how the Tuberculosis form tracks previous TST results and vaccine information.
  • Employee Medical Questionnaire: This form collects detailed information on an employee’s medical history, just like the Tuberculosis form gathers information on past positives and current health conditions.
  • Fit for Duty Certification: This document assesses whether employees meet health requirements for their job, paralleling how the Tuberculosis form ensures suitability for specific roles.
  • Pre-Employment Physical Exam Form: Similar in gathering comprehensive health information, this form assesses an applicant’s overall health before starting a job.
  • Exposure History Form: This document collects information about previous exposures to diseases, akin to the Tuberculosis form’s focus on past TST results and exposure risk.
  • Occupational Health Assessment: This evaluation looks at an employee’s health concerning workplace hazards, echoing the Tuberculosis form's health screening aspect.
  • Immunization Consent Form: This document requires employees to provide consent for vaccinations, similar to how the Tuberculosis form addresses past vaccine-related questions.
  • Health Risk Assessment Questionnaire: This questionnaire identifies potential health risks for individuals, akin to the chronic condition inquiries on the Tuberculosis form.
  • Medical Examination Report: This report outlines findings from a medical exam, similar to how the Tuberculosis form addresses the need for reading and interpreting test results.

Dos and Don'ts

When filling out the Fill In The Blanks On Tuberculosis form, it's important to take care to ensure accuracy and completeness. Here are some things to do and avoid:

  • Do provide your full name and accurate identification details to facilitate processing.
  • Do answer all questions truthfully, especially regarding previous test results and vaccinations.
  • Do ensure you have the TST read by a licensed professional within 48-72 hours of administration.
  • Do keep a copy of the completed form for your records.
  • Don't forget to mention any chronic health conditions you may have on the form.
  • Don't attempt to read your own TST results; the results must be interpreted by a qualified person.

Misconceptions

Misconceptions surrounding the Fill In The Blanks On Tuberculosis form can lead to confusion and potential health risks. Here are some common misunderstandings.

  • Misconception 1: The Tuberculosis Skin Test (TST) is optional for employees.
  • Many individuals believe that undergoing the TST is merely a recommendation rather than a requirement. However, for certain employers, particularly in healthcare or educational settings, the TST is mandated. It serves as a critical screening tool for preventing the spread of tuberculosis in work environments where exposure risk is higher.

  • Misconception 2: A positive TST result automatically means tuberculosis is present.
  • Some people assume that if their TST results are positive, they have active tuberculosis. In reality, a positive result indicates exposure to the bacteria but does not differentiate between latent infection and active disease. Further medical evaluation is essential to determine the individual's health status.

  • Misconception 3: The form is solely for new employees.
  • Individuals may think that the TST form is only required for new hires. In fact, the form is necessary for various circumstances, including annual screenings and post-exposure evaluations. Regular tests help ensure ongoing employee well-being in environments with potential TB exposure.

  • Misconception 4: Anyone can interpret their TST results.
  • Some employees believe they can read their own TST results without professional help. This is a misconception that could lead to misinterpretation. According to the instructions, only licensed personnel are qualified to assess and document TST results, ensuring accuracy and appropriate follow-up actions.

Key takeaways

Filling out the Fill In The Blanks On Tuberculosis form requires careful attention to detail. Here are key takeaways to help you through the process:

  • Provide all personal information accurately, including last name, first name, birth date, and contact numbers.
  • Choose the appropriate reason for screening; this may include pre-placement or annual checks.
  • Indicate if you have had a positive tuberculosis skin test (TST) in the past and provide details if applicable.
  • Check if you have received any live vaccines in the last 30 days, as this can affect test results.
  • Disclose any chronic conditions or symptoms that may be relevant to tuberculosis screening.
  • Understand that TST results must be read by a licensed healthcare professional within 48-72 hours.
  • Take note that you cannot read your own TST results; this must be done by someone qualified.
  • Keep a copy of the completed form for your records to avoid unnecessary charges in the future.
  • Ensure to follow up on any instructions provided after the TST is administered, especially regarding the second step.
  • Act promptly on any adverse reactions to the test and inform your healthcare provider if necessary.

By following these guidelines, you can navigate the tuberculosis screening process more effectively.