Missouri Department of Health and Senior Services

Bureau of Communicable Disease Control and Prevention

Tuberculosis (TB) Risk Assessment Form

Patient’s Name: __________________________________ Date of Birth:______________ Date: _______________

Address: _________________________________________________ Phone Number: _______________________
A. Please answer the following questions (Sections A & B to be completed by Patient):
Have you ever had a positive Mantoux tuberculin skin test (TST)? Yes No
Have you ever been vaccinated with BCG? Yes No
Have you ever had a positive Interferon Gamma Release Assay (IGRA) test? Yes No
Have you ever been diagnosed with or treated for TB Disease? Yes No
B. TB Risk Assessment
Have you ever had close contact with anyone who was sick with tuberculosis? Yes No
Have you ever traveled to one or more of the countries listed below? If yes, please CHECK the countries. Yes No
Were you born in one of the countries listed below? If yes, please list the country:____________________ Yes No
What year did you arrive in the United States? _____________
Afghanistan Cape Verde Gabon Kuwait Myanmar St. Vincent & Tokelau
Algeria Central African Rep. Gambia Kyrgyzstan Namibia The Grenadines Tonga
Angola Chad Georgia Lao PDR Nauru Sao Tome & Principe Trinidad & Tobago
Anguilla Chile Ghana Latvia Nepal Saudi Arabia Tunisia
Argentina China Greenland Lesotho Nicaragua Senegal Turkey
Armenia Colombia Guatemala Liberia Niger Serbia Turkmenistan
Azerbaijan Comoros Guinea Libyan Arab Jamihirya Nigeria Seychelles Sierra Turks & Caicos
Bahrain Congo Guinea-Bissau Lithuania Niue Leone Islands
Bangladesh Congo DR Guam Macedonia-TFYR Northern Mariana Singapore Tuvalu
Belarus Cote d’Ivoire Guyana Madagascar Islands Solomon Islands Uganda
Belize Croatia Haiti Malawi Pakistan Somalia Ukraine
Benin Djibouti Honduras Malaysia Palau South Africa Uruguay
Bhutan Dominica Hungary Maldives Panama Sri Lanka Uzbekistan
Bolivia Dominican Republic India Mali Papua New Guinea Sudan Vanuatu
Bosnia & Herzegovina Ecuador Indonesia Marshall Islands Paraguay Sudan - South Venezuela
Botswana Egypt Iran Mauritania Peru Suriname Viet Nam
Brazil El Salvador Iraq Mauritius Philippines Syrian Arab Republic Wallis & Futuna
Brunei Darussalam Equatorial Guinea Japan Mexico Poland Swaziland Islands
Bulgaria Eritrea Kazakhstan Micronesia Portugal Tajikistan Yemen
Burkina Faso Estonia Kenya Moldova-Rep. Qatar Tanzania-UR Zambia
Burundi Ethiopia Kiribati Mongolia Romania Thailand Zimbabwe
Cambodia Fiji Korea-DPR Morocco Russian Federation Timor-Leste
Cameroon French Polynesia Korea-Republic Mozambique Rwanda Togo

Source: World Health Organization Global Tuberculosis Control, WHO Report 2013, Countries with Tuberculosis incidence rates of > 20 cases per 100,000
population. For future updates, refer to [Link]

Have you ever had an abnormal chest x-ray suggestive of TB? Yes No No Response
Are you HIV positive? Yes No No Response

Are you an organ transplant recipient or donor? Yes No No Response

Are you immunosuppressed (taking an equivalent of > 15 mg/day of prednisone for >1 month, or Yes No No Response
currently taking prescription arthritis medication)?
Are you a resident, employee, or volunteer in a high-risk congregate setting (e.g., correctional Yes No No Response
facilities, nursing homes, homeless shelters, hospitals, and other health care facilities)?
Do you have any medical conditions such as diabetes, silicosis, head, neck, or lung cancer, Yes No No Response
hematologic or reticuloendothelial disease such as Hodgkin’s disease or leukemia, end stage
renal disease, intestinal bypass or gastrectomy, chronic malabsorption syndrome, low body
weight (i.e., 10% or more below ideal)?
Do you have a cough lasting 3 weeks or longer, chest pain, weakness or fatigue, weight loss, Yes No No Response
chills, fever and/or night sweats?
Are you coughing up blood or phlegm? Yes No No Response
I hereby certify that this application contains no misrepresentation or falsification and that the information given by me is true and complete to the
best of my knowledge and belief.

______________________________________ _____________________________________
Patient Signature (Required) Date:

MO 580-3015 (11-13)
 Missouri Department of Health and Senior Services
Bureau of Communicable Disease Control and Prevention
Tuberculosis (TB) Risk Assessment Form

C. Medical Evaluation (Section C to be completed by Health Care Provider – if needed)

Health Care Provider: If the answer to any of the TB Risk Assessment questions in Section B is YES or NO RESPONSE,
proceed with additional medical evaluation as appropriate. Additional evaluation may include one or more of the following:
TST, IGRA, sign and symptom review, chest x-ray, or sputum collection. If the patient is immunosuppressed and no
previous TB test is documented, an IGRA is recommended.
1. Tuberculin Skin Test (TST) - Please provide a 2-step TST for those at high risk that have no documentation of a previous
TST: Administer 1st step TST today and read in 48-72 hrs, if the 1st step TST is positive, document the results in
millimeters (mm)of induration and follow the evaluation steps for a positive TST. If the 1st step TST is negative document the
results in mm of induration. Results of mm of induration, transverse diameter; if no induration write “0” mm. The TST
interpretation* should be based on mm of induration as well as risk factors. Place a 2-step TST in one to three weeks after the
first TST was read and recorded. The 2-step should be read in 48-72 hrs and then follow the documentation procedures as
outlined above .
Date Given: ____________ Date Read: ____________
Result: ________ mm of Induration *Interpretation: Positive____ Negative____
Date Given: ____________ Date Read: ____________
Result: ________ mm of Induration *Interpretation: Positive____ Negative____

*TST Interpretation Guidelines (Please check all that apply).

>5 mm is Positive: Recent close contacts of an individual with > 10 mm is: Persons born in a high prevalence country or who resided in one for
infectious TB Positive: a significant amount of time
Persons with fibrotic changes on a prior chest x-ray History of illicit drug use
consistent with past TB disease Mycobacteriology laboratory personnel
Organ transplant recipients History of resident, worker or volunteer in high-risk congregate settings
Immunosuppressed persons: taking > 15 mg/d of Persons with the following clinical conditions: silicosis, diabetes
prednisone for > 1 month; taking a TNF-α mellitus, chronic renal failure, leukemias and lymphomas, head, neck or
antagonist lung cancer, low body weight (>10% below ideal), gastrectomy or
Persons with HIV/AIDS intestinal bypass, chronic malabsorption syndromes
Children < 4 years of age
>15 mm is Positive: Persons with no known risk factors for TB disease Children and adolescents exposed to adults in high-risk categories

2. Interferon Gamma Release Assay (Please check the IGRA that is used)
QFT-G QFT-GIT Date Obtained: _____________
Result: Responsive (TB Infection Likely) Nonresponsive (TB Infection Unlikely) Indeterminate
T- Spot Date Obtained: ____________
Result: Negative Positive Borderline/Equivocal
Other: __________ Date Obtained: ____________ Result:________________________________
3. Chest X-ray: (Required if TST or IGRA is positive)
Date of Chest X-ray: _________ Result: Normal Abnormal
Abnormal Chest X-ray Interpretation: ______________
4. Sputum Collection: If the patient has a positive TST or IGRA and a productive cough > 3weeks, with or without
hemoptysis, please collect three (3) consecutive sputum, one early morning and all must be at least eight (8) hours apart with a
minimum of 2 milliliters of specimen per tube.
1. Date Obtained Smear Result: Culture Result: 2. Date Obtained: Smear Result: Culture Result:
__________________ ______________ _____________ ______________ _____________ ______________
3. Date Obtained: Smear Result: Culture Result:
__________________ ______________ ______________
An isolate on any positive mycobacterium cultures should be sent to the Missouri State Public Health Laboratory, for further testing questions call
573-751-3334.
I have reviewed the above information with the patient and deemed: No Further Evaluation Needed Further Evaluation is Needed

_________________________________________ _____________________________________
Health Care Provider Signature (Required) Date:
All positive TST, IGRA, chest x-ray, smear and culture results suggestive of tuberculosis disease or latent tuberculosis infection should be reported to the Missouri
Department of Health and Senior Services (fax number: 573-526-0235) or your local public health agency using this form. If you have any questions, please contact
the Bureau of Communicable Disease Control and Prevention at 573-751-6113.

MO 580-3015 (11-13)