Career Annual TB QuestionnairePlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Personal InformationName *FirstLastEmployee’s first and last nameDate *Date completing the screenHealth Related InformationAre you feeling sick or have high fever? *YesNoPlease indicate if you are experiencing any of the following symptoms for three or four weeks or longer? (check all that apply. If any symptom is checked, explain below) *A productive cough for more than 3 weeks in the past yearHemoptysis (coughing up blood)Persistent Shortness of breathUnexplained weight lossUnexplained FatigueFever for no reasonChills for no reasonNight sweats for no reasonNONE OF THE ABOVEIf any box is checked above, please explain belowSignature * Clear Signature Submit Share this: Click to share on X (Opens in new window) X Click to share on Facebook (Opens in new window) Facebook More Click to email a link to a friend (Opens in new window) Email Click to share on LinkedIn (Opens in new window) LinkedIn Click to share on WhatsApp (Opens in new window) WhatsApp Like this:Like Loading...Pages: 1 2
