TB Risk Questionnaire TB Risk Questionnaire Storybook Pediatrics TB Risk Questionnaire 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 Primary email with verification 2. Other Email Confirm 2. Other Email Other email with verification 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? * Email to send my confirmation copy (if different from primary email address above) Confirm Email to send my confirmation copy (if different from primary email address above) Parent or Legal Guardian Signature Clear If you are human, leave this field blank. Submit
