Tuberculosis (TB) Screening Questionnaire

Email Address

First Name

Last Name

USM Student ID no.

Tuberculosis, also known as TB, is a bacterial infection that attacks the lungs and sometimes other parts of the body. It is spread when someone infected with the disease coughs or sneezes and the bacteria is inhaled by someone nearby.

The University of Saint Mary requires ALL students to complete a tuberculosis screening questionnaire, per the Kansas Statute #56-129e.

Residents and athletes must have a completed form on file before moving in to the halls and/or participating in practice.

1. Have you ever had a positive TB test?

Yes

No

2. Have you ever had close contact with someone who was sick with TB?

Yes

No

3. Have you ever had the European childhood BCG vaccine which is given to prevent TB?

Yes

No

4. Were you born in a country other than those listed below?

Yes

No

List of Exempt/Low Incidence/TB Countries**

(Defined by the Department of Health and Environment)

Albania	Costa Rica	Iceland	Samoa
American Samoa	Cyprus	Ireland	Slovakia
Andorra	Czech Republic	Italy	Slovenia
Antigua & Barbuda	Denmark	Jamaica	Spain
Australia	Dominica	Luxembourg	Sweden
Austria	Fuji	Malta	Switzerland
Bahamas	Finland	Nauru	Turks & Caicos Islands
Barbados	France	Netherlands	Great Britain & North Ireland
Belgium	Germany	New Zealand	United States Virgin Islands
British Virgin Islands	Greece	Norway	United States of America
Canada	Grenada	Saint Kitts & Nevis	Wallis & Futuna Islands
Chile	Hungary	Saint Lucia

**Students from countries other than those listed above are required to have a TB test.

5. Have you ever traveled to and/or resided in a country for more than three months which is not listed above?

Yes

No

If you answered 'Yes' to question 5, please explain and list countries and dates.

Signature and agreement

I understand further testing may be required before attending class at the University of Saint Mary. If testing is required I will be responsible for the cost. The information provided in this form is correct to the best of my knowledge.

By typing my name below and clicking the submit button, I agree and understand that the electronic submission of this form constitutes my official signature as stipulated by the University of Saint Mary and the state of Kansas.

Student Signature:

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