TB Risk Questionnaire TB Risk Questionnaire TB Risk Questionnaire Email to receive your copy (Optional. NOTE: Gmail will reject delivery of this form.) Confirm Email to receive your copy (Optional. NOTE: Gmail will reject delivery of this form.) Enter a confirmation email address. Date * (MM/DD/YYYY) Child’s Name * DOB * (MM/DD/YYYY) Street * City * State * Zip * Current Contact Information Mom’s Phone Dad’s Phone 1. Primary Email Confirm 1. Primary Email Enter a confirmation PRIMARY email address. 2. Other Email Confirm 2. Other Email Enter a confirmation OTHER email address. Questions 1. Has your child ever received BCG (a TB vaccine cometimes given in foreign countries)? * Yes No 2. Has there ever been TB, or a positive TB skin test, in any household member? * Yes No 3. Was your child born outside the United States? * Yes No 4. Has your child lived outside the United States for more than a month? * Yes No 5. Was any household member (like the list of people in question 2) born outside the United States? * Yes No 6. Does any household member have HIV or AIDS? * Yes No 7. Has any household member worked in or been put in jail or prison in the last 5 years? * Yes No 8. Has any household member ever lived in a homeless shelter? * Yes No 9. Is your child a foster child or adopted child? * Yes No 10. How would you describe your child’s ethnicity? * 11.a What is the father’s highest level of school completed? * 11.b What is the mother’s highest level of school completed? * Parent or Legal Guardian Signature signature keyboard Clear Submit If you are human, leave this field blank.
