Please read carefully and fill in all required fields.

    1. Write your name
    2. Answer following questions.

Have you ever had close contact with persons known or suspected to have active TB disease? Yes or No.
Were you born in one of the countries listed below that have a high incidence of active TB disease? Yes or No.
If yes,please circle the country below.

  1. Have you had frequent or prolonged visits to one or more of the countries listed above with a high prevalence of TB disease?
  2. Have you been a resident and/or employee of high-risk congregate settings?
  3. Have you been a volunteer or health-care worker who served clients who are at creased risk for active TB disease?
  4. Have you ever been a member of any of the following groups that may have an increase incidence of latent M tuberculosis infection or active TB disease?
  5. Please show the result of this page to your physician or health core provider, and ask to complete the following Part2-2