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TB Attestation

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Aquinas Healthcare Annual Statement of Tuberculosis Screening

* This form is required to be completed by each caregiver and reviewed with the Nurse annually
The following 13 screening questions must be answered by the potential and current employees.

Sign or Symptom

Cough lasting more than three (3) weeks
Coughing up blood (Hemoptysis)
Unexplained fever, chills, or night sweats
Persistent shortness of breath
Unexplained weight loss
Chest pain
Chronic or unusual tiredness or fatigue
Have you had a positive TB skin test in past years?
Have you had contact with anyone with active TB in the past year?
Have you ever had BCG vaccine?
In the past year have you been to another country for one (1) month or more where TB is common?
Have you had contact with anyone who has lived in a county where TB is common during the past year?
Do you have a medical condition, or are you taking medication, which suppresses your immune system?
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