MANDATORY TUBERCULOSIS SCREENING FORM FOR FOURTH YEAR (M4) FAU MEDICAL STUDENTS 2014-2015 Return completed forms by April 17, 2015 to: FAU Immunization Office, SU-80, Room 114, 777 Glades Road, Boca Raton, FL 33431 (561) 297-0048 FAX (561) 297-2769 Physician signature is NOT necessary on this form if other official documents are submitted. Student’s Last name First Name MI Student Z number Birth date Gender Permanent street address City State Zip code Telephone REQUIRED SCREENING 1. Tuberculin Skin Test (PPD) Documentation of a single PPD skin test within 6 months. PPD in last 6 months 1. ____/____/____ Pos 1a. If you had a positive PPD: Complete the Tuberculosis Screening Questionnaire and attach the report from a chest x-ray done within the last 6 months. If positive PPD, date of most recent CXR: ____/____/____ Neg Results: Normal____ Abnormal_____ I certify that the information above is true and accurate to the best of my knowledge. Physician signature: (mandatory) Physician’s printed name: Date Office stamp required TUBERCULOSIS SCREENING QUESTIONNAIRE FOR FOURTH YEAR (M4) FAU MEDICAL STUDENTS 2014-2015 Complete this form only if you have a history of a POSITIVE TB skin test. PERSONAL INFORMATION Last name Z number First name Date of birth MM/DD/YY Phone Email address Have you ever received BCG? Yes No Date of last PPD skin test: Did you take any medication associated with a positive TB test? ___/___/____/ Date of last chest X-Ray: ___/____/____/ Yes No Gender If yes, date of BCG vaccine: ___/___/____/ If yes, dates:_______________________ Check if you are having any of the following unexplained symptoms and they have lasted for 3-4 weeks or longer Symptom Unexplained fatigue Unexplained weight loss Loss of appetite Fever (usually at night) Yes No Symptom Night sweats (drenching) Persistent cough Spitting/coughing up blood Chest pain Yes No HEALTH CARE PROVIDER CERTIFICATION AND ADDRESS I certify that the information provided above in the section on TB screening is true and accurate to the best of my knowledge. Physician’s printed name: An official stamp must appear here for forms and documents to be approved. Street Address Physician’s signature: City State Zip Date Attach copy of the x-ray report to this form and return to: FAU Immunization Office, SU-80, Room 114, 777 Glades Road, Boca Raton, FL 33431 (561) 297-0048 FAX (561) 297-2769