Is the form legally enforceable?

Yes. Electronic completion and signatures are enforceable if they meet ESIGN requirements: intent to sign, consent to an electronic process, attribution to the signer, and ability to retain and reproduce the record. UETA applies where adopted by the state; ESIGN (15 U.S.C. ch. 96) governs interstate transactions.

Can the form include protected health information (PHI)?

Yes, it can contain PHI for occupational health purposes. When PHI is stored or transmitted electronically, HIPAA safeguards apply and a Business Associate Agreement (BAA) is typically required with the service provider.

Is a handwritten signature required?

No. A variety of electronic signature types are acceptable under ESIGN/UETA if intent and attribution are captured, but some employers or clinical partners may require clinician wet signatures for certain medical determinations.

When must a positive TB result be reported?

Reporting requirements vary by state; most jurisdictions require prompt reporting of confirmed active TB to the local health department. Follow state public health rules and internal reporting timelines.

How should I store signed forms?

Store signed records in encrypted, access-controlled systems with an audit trail. Preserve the original signed record and associated metadata to meet retention rules and support audits.

What if employee data is entered incorrectly?

Correct errors via an auditable amendment process rather than deleting entries. Maintain the original entry and a clear correction log showing who made the change and why.

Electronic Signature
Templates
HR
Employee TB Screening Form

Employee TB Screening Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

EMPLOYEE TB SCREENING FORM

Purpose: The purpose of this form is to document tuberculosis (TB) risk assessment, testing history, and clinical evaluation necessary for occupational health clearance. The information provided will be maintained confidentially in the employee medical record and used to determine fitness for duty and any required treatment or work restrictions.

Personal Information

Full Legal Name

Date of Birth:

Employee ID:

Home Address

Phone

Email

Position Information

Job Title

Department

Reporting Manager

Start Date:

Proposed Salary:

Employment History (Most Recent Employers)

Employer 1 — Company Name

Title:

Dates Employed: From To

Primary Responsibilities Reason for Leaving

Employer 2 — Company Name

Title:

Dates Employed: From To

Primary Responsibilities Reason for Leaving

Education

Highest Degree Institution

Graduation Date:

Professional References

Reference 1

Reference 2

Reference 3

TB Risk Assessment — Symptoms and Exposure

Please answer the following. Check the box that applies. A positive response may require testing or medical evaluation.

1. Persistent cough lasting more than three weeks:

Yes No

2. Unexplained weight loss, fever, or night sweats in the past month:

Yes No

3. Known close contact with someone with active pulmonary TB:

Yes No

4. Prior diagnosis of active TB disease:

Yes No

5. Prior positive TB skin test or positive interferon-gamma release assay (IGRA):

Yes No

6. BCG vaccination (given at birth or later):

Yes No

TB Testing History

Provide dates and results for prior TB testing and imaging. Attach supporting documentation when available.

Tuberculin Skin Test (Mantoux)

Date Administered:

Administered By:

Result (mm induration):

Interpretation: Positive Negative

Interferon-Gamma Release Assay (IGRA)

Date:

Lab/Facility:

Result: Positive Negative

Chest Radiograph Findings Prior Treatment for Latent or Active TB

Yes No

If yes, provide treatment details

Occupational Health Assessment and Recommendations

To be completed by occupational health clinician: indicate findings, clearance status, recommended restrictions, or therapy referrals below.

Cleared for work — no restrictions

Cleared for work — with restrictions (specify below)

Requires treatment/further evaluation

Not cleared for work pending evaluation/treatment

Clinical Comments / Recommended Follow-up

Clinician Name:

Clinician Title:

Date:

Legal Notices, Consent and Certification

Confidentiality: Results of TB testing and related medical records are confidential and will be retained in the employee medical file separate from the general personnel file. Information will be disclosed only as required for treatment, public health reporting, or as permitted by law.

Consent to Testing and Release: By signing below, I authorize the employer and its occupational health provider to perform TB screening tests (including skin tests, blood tests, and chest radiographs as indicated), to obtain prior TB-related medical records, and to communicate test results to the employer when necessary to determine fitness for duty. I authorize release of TB-related information to treating clinicians for continuity of care.

Applicant Certification: I certify that the information I have provided on this form is true, complete, and accurate to the best of my knowledge. I understand that withholding or misrepresenting information may affect my employment status. I authorize verification of the information contained herein and consent to any reasonable inquiries needed to evaluate my TB status for employment.

At-Will Employment Statement: Nothing in this form changes any existing at-will employment relationship. Employment may be terminated with or without cause and with or without notice, unless otherwise agreed in writing.

Equal Opportunity: This employer provides equal employment opportunities and does not discriminate on the basis of protected characteristics. TB screening is conducted for legitimate occupational health reasons and in accordance with applicable laws and regulations.

Authorization to Contact Previous Employers and Conduct Background Checks: I authorize the employer to contact previous employers and other references listed on this form for purposes consistent with employment evaluation, including verification of job-related history and fitness for duty. I understand that such inquiries may include medical work history related to communicable diseases when job-related and permitted by law.

Employee Consent: I consent to testing and records release as stated above.

Applicant Signature

Employee Printed Name:

Signature:

Date:

What the Employee TB Screening Form Is and when it's used

The Employee TB Screening Form is a workplace health questionnaire and record used to document tuberculosis (TB) risk factors, symptom checks, and test results for employees. Employers use the form during onboarding, after exposure events, or for periodic surveillance to protect staff and patients. The form captures identifying information, screening responses, test dates and outcomes, and the name of the clinician or facility conducting any diagnostic testing. Records produced by this form may be subject to health privacy and workplace-recordkeeping rules and should be managed accordingly.

Why employers keep a formal Employee TB Screening Form

A consistent TB screening form helps employers meet workplace health obligations, document due diligence, and support timely clinical follow-up. Properly completed forms reduce legal and operational uncertainty; where electronic signatures or records are used, ESIGN (15 U.S.C. ch. 96) and state UETA frameworks support enforceability when consent, attribution, and retention requirements are met.

Who fills and reviews these forms in an organization

Typical users include HR, occupational health nurses, clinic staff, and hiring managers who manage employee medical clearances.

HR and People Ops: Collects screenings at hire and maintains employee records securely.
Occupational Health / Clinicians: Performs symptom checks, orders tests, and records clinical findings.
Public Health / Safety Officers: Reviews positive results for case management and reporting, per jurisdiction rules.

External parties may review results: authorized clinicians, public health authorities, and, when required, designated safety officers.

Step-by-step: completing the Employee TB Screening Form

Follow this sequence to ensure a complete, compliant screening record for each employee.

01

1. Identify: Enter employee full legal name and employer ID.
02

2. Screen: Record symptom questions and exposure history responses.
03

3. Test: Document test type, date, and result if testing performed.
04

4. Certify: Clinician signs and dates; employer records action taken.

Security and compliance controls for handling screening records

Encryption: TLS 1.2/1.3 in transit; AES-256 at rest

HIPAA: HIPAA-compliant storage; BAA required

Audit Trail: Timestamps, IP, and action log

Access Controls: Role-based permissions and SSO options

Certifications: SOC 2 Type II and ISO 27001 available

Accessibility: WCAG 2.0 Level AA support

Consequences of incomplete or mishandled screening records

HIPAA Exposure: Civil and criminal penalties possible

OSHA Noncompliance: Citations and monetary penalties

Report Failures: Public health reporting violations

Worker Safety Risk: Increased exposure and liability

Record Loss: Evidence gaps for audits

Data Breach Costs: Notification and remediation expenses

Common mistakes when preparing TB screening records

Incomplete dates or inconsistent date formats create ambiguity for follow-up and retention schedules, leading to potential compliance gaps.
Using informal names or initials instead of legal names prevents reliable matching to medical or public health records during investigations.
Failing to capture the test type or result code forces reliance on secondary lab records and delays occupational health decisions.
Storing screening data in unsecured email or shared drives risks unauthorized access and possible HIPAA violations.

Typical workflow for collecting and closing a screening record

A straightforward digital workflow reduces friction and improves traceability from screening to resolution.

Upload Template: Load form as PDF or DOCX and prepare fields.
Assign Signers: Add employee and clinician emails or signer roles.
Authenticate: Choose email link, SMS code, or stronger methods.
Complete & Store: Signed record and audit trail archived securely.

Key online settings to configure for TB screening workflows

Configure these fields when deploying the form to ensure required data, security, and storage are in place.

Field	Configuration
Authentication Method	Email link, SMS code, or multi-factor authentication
Required Fields	Make name, date, test type, and result mandatory
Access Expiration	Set signing link expiry to 7–30 days
Storage Location	Choose encrypted cloud storage with retention policy

Technical and integration considerations for digital submission

Ensure the platform supports secure file formats, signer authentication, and integration with your HR or EHR systems.

File Formats: PDF and DOCX supported
Integrations: Salesforce, NetSuite, Google Workspace
Authentication: Email, SMS, or stronger methods

Timing considerations and routine deadlines

Establish clear timing rules for initial screening, post-exposure testing, and periodic follow-up to meet workplace safety and public health expectations.

Initial Onboarding Screening:

Complete at hire or first workplace entry.

Post-Exposure Testing:

Initiate testing immediately after confirmed exposure.

Periodic Follow-up:

Follow employer policy or local guidance for re-screening frequency.

Public Health Reporting:

Report confirmed active TB per state rules promptly.

Record Retention Start:

Retention begins on screening or test result date.

Key milestones from screening to closure

Track these sequential stages to verify completion, clinical review, and archival for each employee screening episode.

01

Pre-employment Screening

Collect baseline symptom history and prior TB treatment information.

02

Diagnostic Testing

Order or document TST/IGRA and chest imaging as indicated.

03

Clinical Evaluation

Clinician reviews results and documents clearance or treatment.

04

Reporting & Retention

Report positive cases and archive records per policy.

How the Employee TB Screening Form differs from a lab test result

Quick comparison to clarify when to use a screening form versus a formal laboratory or clinical report.

Document Type	TB Screening	TB Test Result
Purpose	workplace screening	diagnostic confirmation
Timing	pre-employment or surveillance	at specimen collection
Provider	employer/clinician	laboratory or imaging center
Retention	employer health record	clinical/lab record

eSignature vendor comparison for submitting Employee TB Screening Forms

Basic vendor comparisons for common criteria. signNow is listed first; confirm plan specifics with each vendor before purchase.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial, no credit card required	Contact vendor for current trial options	Contact vendor for current trial options	Contact vendor for current trial options	Contact vendor for current trial options
Bulk Send	Yes, included on paid plans	Yes, included on paid plans	Yes, included on paid plans	Yes, included on paid plans	No, not available on standard plans
Audit Trail	Yes, detailed audit trail included with every signing	Yes, audit trails included	Yes, audit trails included	Yes, audit trails included	Yes, audit trails included
HIPAA Compliant	Yes, BAA available on request	Yes, BAA available	Yes, BAA available	No, BAA not offered by PandaDoc	No, BAA not offered by HelloSign
Envelope Cap	No envelope cap — unlimited envelopes	Limited to 100 envelopes per user per year	Varies by plan; contact vendor	Varies by plan; contact vendor	Varies by plan; contact vendor

FAQs and troubleshooting for the Employee TB Screening Form

Answers to common questions about legality, signatures, privacy, and practical handling of screening records.

Need help? Contact support

Is the form legally enforceable?
Yes. Electronic completion and signatures are enforceable if they meet ESIGN requirements: intent to sign, consent to an electronic process, attribution to the signer, and ability to retain and reproduce the record. UETA applies where adopted by the state; ESIGN (15 U.S.C. ch. 96) governs interstate transactions.
Can the form include protected health information (PHI)?
Yes, it can contain PHI for occupational health purposes. When PHI is stored or transmitted electronically, HIPAA safeguards apply and a Business Associate Agreement (BAA) is typically required with the service provider.
Is a handwritten signature required?
No. A variety of electronic signature types are acceptable under ESIGN/UETA if intent and attribution are captured, but some employers or clinical partners may require clinician wet signatures for certain medical determinations.
When must a positive TB result be reported?
Reporting requirements vary by state; most jurisdictions require prompt reporting of confirmed active TB to the local health department. Follow state public health rules and internal reporting timelines.
How should I store signed forms?
Store signed records in encrypted, access-controlled systems with an audit trail. Preserve the original signed record and associated metadata to meet retention rules and support audits.
What if employee data is entered incorrectly?
Correct errors via an auditable amendment process rather than deleting entries. Maintain the original entry and a clear correction log showing who made the change and why.

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