Name (please print): ____________________

Date of Birth:__________ Today’s Date: __________

PLEASE ANSWER THE FOLLOWING QUESTIONS:

1. To the best of your knowledge have you ever had close

contact with anyone who was sick with tuberculosis (TB)?

 

2. Have you ever had a positive (reactive) TB skin test in the past?

 

3. Were you born in any country other than Australia, Canada, Japan,

New Zealand, United States, or Western European countries?

 

4. Have you traveled or lived for more than one month in any country

other than Australia, Canada, Japan, New Zealand, United States,

Western Europe countries, or lived on an Indian reservation in the

United States?

 

5. Have you ever lived or worked in a homeless shelter or prison?

 

If you answered yes to any of the above questions, please explain:

 

When and where did you last have a TB screening test?

 

 

If you answered no to all 5 of the above questions you do not need to do anything further. If you answered yes to any of the questions, please print this form and send it to us by postal mail, fax or e-mail.

UMF-STUDENT HEALTH CENTER
111 SOUTH STREET
FARMINGTON, ME 04938
Fax: 207-778-8183
TShaw@maine.edu