Establishing secure connection…Loading editor…Preparing document…

Healthcare TB Screening Questionnaire

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

HEALTHCARE TB SCREENING QUESTIONNAIRE

The following questionnaire is used to screen for tuberculosis (TB) infection or disease. Please answer all items accurately. Information collected will be maintained in the patient record and handled in accordance with applicable privacy laws and public health reporting requirements. By signing this form, you certify that the information provided is true and you consent to TB screening and any diagnostic testing deemed necessary by your healthcare provider.

Patient Information

Date of birth:

Gender:

Insurance Information

Medical History

Prior tuberculosis history:

I have been treated for active tuberculosis in the past. If yes, provide year and treatment facility:

Received BCG vaccination. Year (if known):

Chronic conditions (check all that apply)

HIV/AIDS Diabetes

Organ transplant / chronic immunosuppressive therapy Silicosis

TB Screening Questions

Check any item that currently applies to you or that has applied within the past 12 months.

Persistent cough lasting 3 weeks or longer

Coughing up blood (hemoptysis)

Unintentional weight loss

Fever or night sweats

TB exposure and risk factors (check all that apply)

Recent close contact with a person known to have active TB disease

Born in or traveled to a country with high TB prevalence within the past 5 years

Current or recent residence in a correctional facility, homeless shelter, long-term care facility, or other institutional setting

Prior TB Testing

Prior tuberculin skin test (TST/PPD). If yes, date given: Result:

Prior interferon-gamma release assay (IGRA). If yes, date: Result:

Prior chest radiograph abnormal for TB. If yes, date:

Provider Assessment (for clinical staff)

TST / IGRA ordered Chest radiograph ordered Follow-up appointment/date:

Privacy and Certification

I acknowledge that I have been offered or provided a copy of the facility's Notice of Privacy Practices. I understand that information on this form will be used for clinical care and may be disclosed to public health authorities as required by law for disease control and reporting.

By signing below I certify under penalty of law that the information on this form is true and complete to the best of my knowledge. I consent to TB screening, diagnostic testing, and reporting to public health authorities where legally required.

Patient Name:

Signature:

Date:

If signed by guardian, relationship to patient:

Enter text✕
Prepare your document for signing right on this page
  • 01 Edit the text and complete the fields
  • 02 Click Sign Now and on the next screen add recipients and signature fields in SignNow
  • 03 Start your free trial to sign and send your doc
Sign Now

What the Healthcare TB Screening Questionnaire Is and Why It Exists

The Healthcare TB Screening Questionnaire is a standardized clinical form used in U.S. healthcare and occupational settings to assess individual risk for tuberculosis. It collects demographics, symptom screening, recent exposure history, prior TST/IGRA results, vaccination status, and immunocompromising conditions. Responses guide clinicians and occupational health staff on testing, chest x‑ray referrals, isolation measures, and treatment pathways. The form can be delivered on paper or electronically; when electronic, apply HIPAA protections and an auditable record of consent and signature.

Why a Formal TB Screening Questionnaire Matters in Clinical Workflows

A structured Healthcare TB Screening Questionnaire provides consistent risk assessment, documents clinical decisions, supports rapid triage and isolation when needed, and creates an auditable record for occupational health and public health reporting while aligning with HIPAA requirements.

Why a Formal TB Screening Questionnaire Matters in Clinical Workflows

Who Typically Completes or Signs the Questionnaire

Common users and signers include clinical staff, occupational health teams, infection preventionists, and patients or employees being screened.

  • Occupational health programs screening new hires, periodic employees, or high-risk staff in hospitals and long-term care.
  • Primary care and specialty clinics screening symptomatic patients, recent exposures, or pre-procedure evaluations.
  • Public health departments using forms for contact investigations and community screening events.

Assign the signer role based on setting and access to medical information; ensure the completing person can verify prior test history.

Core Sections Found on a Professional TB Screening Questionnaire

A professional Healthcare TB Screening Questionnaire balances clinical detail with clear navigation, collecting exposure history, symptoms, testing history, risk factors, and explicit follow-up instructions to support safe clinical and workplace decisions.

Identification

Name, date of birth, medical record or employee ID, contact information, and responsible clinician or department so results are matched correctly.

Symptom checklist

Standardized yes/no prompts for cough, fever, night sweats, weight loss, hemoptysis, and duration fields to assess the likelihood of active TB.

Exposure history

Recent household or workplace contact with known TB cases, travel to high-prevalence regions, and dates or duration of identified exposures to guide testing.

Testing & vaccination

Prior TST (PPD) or IGRA results with dates, BCG vaccination status, and previous chest x‑ray findings to avoid unnecessary repeat testing.

Risk conditions

Immune suppression, HIV, diabetes, steroid use, pregnancy, or age-related risks that increase progression likelihood and affect management choices.

Follow-up actions

Clear next steps based on responses: order IGRA/TST, chest x‑ray, isolation precautions, referral to TB clinic, and documentation requirements for occupational records.

Essential Data Elements Collected on the Form

Full Legal Name: Exact legal name as on ID
Date of Birth: Use MM/DD/YYYY format
Contact Information: Phone, address, and email
Symptoms Checklist: Yes/no responses with duration
Exposure History: Dates and exposure setting
Prior TB Tests: TST/IGRA dates and results

Stepwise Process to Complete and Triage the Questionnaire

Follow these sequential steps when administering or completing the Healthcare TB Screening Questionnaire to ensure consistent triage and documentation across settings.

  • 01
    Collect ID: Verify identity before recording data
  • 02
    Screen Symptoms: Ask checklist questions and record durations
  • 03
    Document Exposure: Record recent contacts and high-risk travel
  • 04
    Decide Next Steps: Order IGRA/TST, chest x‑ray, or isolation as indicated

Configuring an Online TB Screening Workflow

Typical online setup options for digitizing and routing the Healthcare TB Screening Questionnaire within an eForm platform.

Field Online Setting | Notes
Form Title Visible name | Use 'Healthcare TB Screening Questionnaire' for consistency
Pre-fill Demographics Enable auto-fill | Use MRN or employee ID to populate fields
Required Fields Enable validation | Symptoms and consent fields required
Routing Assign destination | Occupational health or TB clinic inbox

Technical and Security Considerations for Electronic Completion

Electronic completion requires a secure e-signature platform with audit trails, a HIPAA Business Associate Agreement when handling PHI, and support for common clinical file formats.

  • Authentication: Email, SMS, or advanced options
  • Integrations: Salesforce, Microsoft 365, NetSuite, Google Workspace
  • File Types: PDF, DOCX, HTML, Excel

Where Completed Questionnaires Are Routed and Stored

After completion, route the Healthcare TB Screening Questionnaire to the appropriate electronic medical record, occupational health service, or public health authority following local protocols.

  • EMR Entry: Scan or import into patient record
  • Occupational Health: Route to employer health unit for employee records
  • Public Health Reporting: Notify local health department for suspected active TB
  • TB Clinic Referral: Send completed form with referral documentation

Timing Expectations After Questionnaire Completion

Timelines and processing expectations vary by setting, but certain actions are time-sensitive for infection control and reporting.

Immediate action:

Isolate and clinically evaluate if active TB suspected; same-day precautions

Diagnostic testing:

Order IGRA/TST and chest x‑ray within 24–72 hours as indicated

Public health notification:

Report suspected infectious TB to local health department promptly

Employee screening cadence:

Baseline at hire; repeat annually or after exposure for high-risk staff

Result documentation:

File in EMR and occupational health record; retain per HIPAA rules

Key Milestones from Screening to Resolution

Sequential milestones describe the path from questionnaire completion to final clinical or administrative resolution.

01

Screening Completed

Questionnaire received and reviewed by clinical staff within 24 hours

02

Triage Decision

Determine need for testing, isolation, or routine follow-up

03

Testing Completed

Perform IGRA/TST and chest x‑ray; document results

04

Resolution

Communicate results, initiate treatment or clearance, and close record

Common Mistakes to Avoid When Preparing the Questionnaire

  • Incomplete or inconsistent patient identifiers such as misspelled name or missing DOB delay matching tests and can cause duplicate records or incorrect treatment.
  • Vague exposure descriptions such as 'contact at work' without dates or duration can cause unnecessary testing or missed high-risk contacts.
  • Failure to record prior TST/IGRA dates and results leads to redundant testing, duplicate imaging, and potential incorrect clinical decisions.
  • Not obtaining or documenting patient consent for electronic record retention or failing to secure PHI increases legal and compliance risk under HIPAA.

Primary Risks and Potential Regulatory Consequences

HIPAA Exposure: Breach fines and corrective action
Reporting Failure: Possible public health penalties
Occupational Liability: Workplace outbreak risk
Clinical Harm: Delayed diagnosis, increased morbidity
Regulatory Citations: State public health codes
Reputational Risk: Loss of trust, litigation exposure

eSignature Vendor Pricing Snapshot for Clinical Questionnaire Workflows

Representative pricing and capability comparisons to consider when selecting an e-signature provider for Healthcare TB Screening Questionnaire workflows; signNow is listed first per vendor data.

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 trial Varies by plan Varies by plan Varies by plan Varies by plan
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Practical Use Cases from Clinical and Occupational Settings

Two concise scenarios illustrate typical uses of the Healthcare TB Screening Questionnaire and the operational outcomes achieved.

Hospital Occupational Health

A tertiary hospital standardized a TB screening questionnaire across campuses to streamline baseline and post-exposure assessments.

  • Reduced redundant testing and improved result tracking.
  • Centralized electronic capture allowed occupational health to triage staff quickly, schedule IGRA testing, document clearance decisions, and produce audit-ready reports for inspections and compliance.

University Student Health

A university adopted the form for fall-term intake screening and outbreak response coordination.

  • Improved student follow-up and isolation management.
  • Electronic submission enabled same-day review by student health clinicians, rapid notification of close contacts, and organized reporting to public health authorities for cluster investigation.

Answers to Frequently Asked Questions About Using the Questionnaire

Common operational and legal questions are answered below to support correct use, electronic signature validity, retention, and error correction procedures.


Need help? Contact support

be ready to get more
Join over 28 million airSlate SignNow users
Sign Now
Company
Forms
Pricing
Resources
Knowledge base
Other Products
© 2026 airSlate Inc. All rights reserved.