Infiniti Home Health Care, LLC

TB Screening

* = Required Information

Do you currently have any of the following that has lasted three (3) weeks or longer?

Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

Have you ever:

Yes No
Yes No
Yes No
Yes No

EMPLOYER REVIEW:
I) If the employee answers yes to any question 1-9, document the objective reason for the symptom. If there is no known reason for the symptom lasting 3 weeks or longer, the employee is to have a TB skin test.
II) If the employee answers yes to any question A-B, the employee is to have a TB skin test.
III) If the employee answers yes to question C, the employee is to have either a chest x-ray or a physician statement noting the employee is free from communicable disease.
I II III None

Administrative Review:


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