Tuberculosis Risk Assessment
(Page 1 of 2)
Name: ______________________________________________________________________________________ Date: _____________
Last First Middle Initial
Date of Birth: ______________ Student ID #: __________________ Phone Number: __________________ E-mail: _________________________
Country of Birth: ________________________ Student Signature: __________________________________
All students must answer the following questions by circling the correct answer. If you answered yes to any question, your healthcare
provider must complete and sign the second page.
1. Have you ever had a positive tuberculosis test? Yes No
2. Have you traveled or lived for more than one month in any of the countries listed below? Yes No
3. Have you had close contact with anyone who was sick with tuberculosis? Yes No
4. Were you born in any of the countries listed below? Yes No
If yes, what country: __________________________________ Date of Entry into USA: _______________________
COUNTRIES WITH HIGH RATES OF TUBERCULOSIS (TB)
Afghanistan El Salvador Lithuania Romania
Algeria Eritrea Macau(SAR of China) Russian Federation
Angola Ethiopia Madagascar Rwanda
Armenia Fiji Malawi Sao Tome & Principe
Azerbaijan Gabon Malaysia Senegal
Bangladesh Gambia Maldives Sierra Leone
Belarus Georgia Mali Singapore
Benin Ghana Marshall Islands Solomon Islands
Bhutan Greenland Mauritania Somalia
Bolivia Guam Micronesia (Federal State of) South Africa
Botswana Guinea Moldova Sri Lanka
Brazil Guinea-Bissau Mongolia Sudan
Brunei Darussalam Guyana Morocco Sudan, South
Burkina Faso Haiti Mozambique Swaziland
Burundi Honduras Myanmar Tajikistan
Cambodia Hong Kong (SAR of China) Namibia Tanzania
Cameroon India Nauru Thailand
Cape Verde Indonesia Nepal Togo
Central African Republic Iraq Nicaragua Turkmenistan
Chad Kazakhstan Niger Tuvalu
China (including Taiwan) Kenya Nigeria Uganda
Congo Kiribati Northern Mariana Islands Ukraine
Congo Demographic Republic Korea, North Pakistan Uzbekistan
Cote d’Ivoire Korea, Republic of Palau Vanuatu
Djibouti Kyrgyzstan Panama Vietnam
Dominican Republic Lao Papua New Guinea Yemen
East Timor Latvia Paraguay Zambia
Ecuador Lesotho Peru Zimbabwe
Equatorial Guinea Liberia Philippines
Libya
Upload your tuberculosis screening form directly into the Medicat Patient Portal at [Link] If you cannot access
the portal, fax to (508) 999-8985 or mail to: Student Health Services, University of Massachusetts Dartmouth, 285 Old Westport Road,
North Dartmouth, MA 02747-2300 Office Phone (508) 999-8982
1
Tuberculosis Risk Assessment
(Page 2 of 2)
Name: ______________________________________________________________________________________ Date: _____________
Last First Middle Initial
Date of Birth: ______________ Student ID #: _________________ Phone Number: _______________ Country of Birth : _____________________
Tuberculosis Testing
Students who responded yes to any of questions 2 through 4 on Page 1 of the TB Risk Assessment form, must have tuberculosis testing done.
All international students who responded yes must have the IGRA blood test for tuberculosis. Tuberculosis skin testing will not be accepted.
All other students may choose between the IGRA blood test or Tuberculin skin test.
IGRA ( Interferon Gamma Release Assay) blood Test Only accepted test result for international students
Date of IGRA Blood Test ______________ Circle Result Positive Negative ATTACH COPY OF LAB
Month/Day/Year
OR
Tuberculosis skin test (Mantoux, PPD) NOT ACCEPTED FOR INTERNATIONAL STUDENTS
Date given ____/____/______ Date Read ____/____/____ Result _______mm of induration
month/day/year
Interpretation _______Negative ______Positive
GUIDE TO INTERPRETATION OF TUBERCULOSIS SKIN TESTING
5 mm or greater is positive 10 mm or more is positive 15 mm or more
is positive
-Recent close contacts of an individual with infectious -Persons born in a high prevalence country or who resided in one for a -Persons with
tuberculosis significant amount of time no known risk
-Persons with fibrotic changes on a prior chest x-ray -History of illicit drug use factors for TB
consistent with past TB disease -Mycobacteriology laboratory personnel disease
-Organ transplant recipients -History of resident, worker or volunteer in high-risk congregate
-Immunosuppressed persons taking ˃15 mg/d of settings
prednisone for ˃1 month: taking a TNF antagonist -Persons with the following clinical conditions; silicosis, diabetes
-Persons with HIV/AIDS mellitus, chronic renal failure, leukemias and lymphomas, head, neck
or lung cancer, low body weight (˃10% below ideal), gastrectomy
or intestinal bypass, chronic malabsorption syndrome
If Tuberculosis testing is positive, now or by history, the following are required:
Date of positive TB test ____/_____/____ Circle test : IGRA (Attach copy of Lab) or TST mm of induration _________
Chest X-ray result ______Normal ______Abnormal (attach report not the x-ray ) Date of X-ray _____/_____/____
Treatment _____No ______Yes
Drug(s), dose, frequency, and dates __________________________________________________________________________________________
__________________________________________________________________________________________
Health Care Provider
Name: _______________________________________ Address: ______________________________________________________________
Signature: _____________________________________________ Phone: _________________________________________
Upload your tuberculosis screening form directly into the Medicat Patient Portal at [Link] If you cannot access
the portal, fax to (508) 999-8985 or mail to: Student Health Services, University of Massachusetts Dartmouth, 285 Old Westport Road,
North Dartmouth, MA 02747-2300 Office phone (508) 999-8982