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Tuberculosis (TB) Screening and Testing …

Student health & Wellness University of Iowa 4189 Westlawn Iowa City, IA 52242 Name _____ Address _____ _____ University ID _____ Tuberculosis (TB) Screening and Testing Questionnaire CIRCLE ANSWERS 1. How old are you? _____ 2. Have you ever had a vaccine to prevent Tuberculosis (BCG vaccine)? (Usually given as infant or child. You may have scar on your arm from the vaccine) NO YES UNKNOWN 3. Have you ever had a positive/reactive TB skin test? NO YES; date: 4.

Student Health & Wellness University of Iowa 4189 Westlawn Iowa City, IA 52242 Name _____ Address _____

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