Can this form be signed electronically?

Yes. Electronic signatures are legally valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided intent, consent, attribution, and record retention requirements are satisfied.

Is patient consent required?

Yes. Use clear consent language if the questionnaire triggers testing or data sharing; for consumer-facing health services ESIGN consumer disclosure requirements apply.

How should I store completed forms?

Store completed medical questionnaires separately from personnel files with access controls. Follow HIPAA retention guidance and applicable state retention rules.

When must active TB be reported?

Confirmed active TB must be reported to the local public health authority immediately, per state reporting requirements and public health statutes.

What if an employee refuses to complete it?

Document refusal, assess workplace risk, consult occupational health and legal counsel for accommodation and public health obligations.

Can HR see detailed medical answers?

No. Share only work-relevant clearance status with HR; detailed clinical information should remain with medical staff to comply with HIPAA privacy protections.

Electronic Signature
Templates
HR
HR TB Questionnaire

HR TB Questionnaire

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

HR TB QUESTIONNAIRE

Purpose: This Tuberculosis (TB) Questionnaire is used to identify risk factors, symptoms, and prior testing or treatment for tuberculosis for purposes of occupational health screening and infection control. The information provided is confidential, maintained separately from general personnel files, and will be used only for medical evaluation, reasonable accommodation determinations, and workplace health decisions consistent with applicable law. Failure to provide accurate information may result in delay of placement, denial of work assignments, or disciplinary action.

Personal Information

Full Legal Name Home Address

Phone:

Email:

Date of Birth:

Employee ID (if any):

Work Location:

Position Information

Job Title Department / Unit

Reporting Manager:

Proposed Start Date:

TB Screening Questions

For each question below, check the response that applies. If Yes, provide dates and explanations in the space provided immediately following the question.

1. Have you ever had a positive tuberculin skin test (TST) or interferon-gamma release assay (IGRA)?

Yes No

If yes, date of positive test and location

2. Have you ever been treated for latent TB infection (LTBI) or active TB disease?

Yes No

If yes, provide treatment details (medication, start/end dates, prescribing provider)

3. Have you had a chest X-ray, CT scan, or other imaging that showed evidence of TB disease?

Yes No

If yes, date and findings (brief)

4. In the past 12 months, have you had any of the following symptoms? Check all that apply.

Cough lasting more than 2 weeks Coughing up blood Unexplained fever Night sweats Unexplained weight loss

If any symptoms checked above, describe onset, duration, and severity

5. Have you had close contact with a person known to have active tuberculosis disease within the past five years?

Yes No

If yes, date and circumstances of exposure

6. Have you received BCG vaccination?

Yes No

If yes, year or approximate age at vaccination

7. Do you have any medical conditions or take medications that suppress the immune system (e.g., corticosteroids, chemotherapy, biologic agents, organ transplant)?

Yes No

If yes, list condition(s) and medications

8. For persons of childbearing potential: Are you currently pregnant or planning pregnancy in the near future?

Yes No Unsure

Prior Employment / Exposure History

List workplaces in the past five years where you had close contact with patients, residents, clients, or coworkers in healthcare, laboratory, congregate living, correctional, or other high-risk settings.

Employer 1 — Facility/Company

Title/Role:

Dates Employed:

Responsibilities and potential TB exposure Employer 2 — Facility/Company

Title/Role:

Dates Employed:

Responsibilities and potential TB exposure

Education

Highest Degree or Certification Institution Graduation Date

References (Professional)

Reference 1 — Name

Phone:

Email:

Relationship Reference 2 — Name

Phone:

Email:

Relationship Reference 3 — Name

Phone:

Email:

Relationship

Legal Disclosures and Authorizations

At-Will Employment: Submission of this questionnaire, any required medical testing, or receipt of occupational health clearance does not alter the at-will employment relationship where applicable. Either the employee or the employer may terminate employment at any time, for any lawful reason, unless otherwise agreed in writing.

Equal Opportunity: The employer provides equal employment opportunities and does not discriminate on the basis of disability, pregnancy, or other protected characteristics. Medical information collected through this questionnaire will be used consistent with applicable nondiscrimination and privacy laws.

Authorization to Contact Prior Employers and Conduct Background Checks: I authorize the employer and its agents to contact prior employers and references listed on this form for employment verification and to conduct background checks as required for my position. I understand that such checks may include verification of employment history, credentials, and other job-related screening consistent with applicable law.

I authorize the employer to contact prior employers and conduct background checks as described above.

Consent for TB Testing and Medical Evaluation

I consent to TB screening tests determined necessary by occupational health, including tuberculin skin test (TST), interferon-gamma release assay (IGRA), and chest radiography where indicated. I understand that additional medical evaluation may be required based on results or symptoms, and that employer-directed evaluations are job-related and consistent with business necessity.

I consent to TB testing and job-related medical evaluation.

Applicant Certification

I certify that all information provided on this HR TB Questionnaire is true, correct, and complete to the best of my knowledge. I understand that knowingly providing false information or omitting relevant facts may result in disciplinary action up to and including termination of employment or withdrawal of an offer. I acknowledge that follow-up testing or medical evaluation may be required and agree to comply with occupational health requirements to determine clearance for duties.

I certify the statements above and affirm accuracy of this questionnaire.

Occupational Health Use Only (Do Not Complete by Applicant)

Clinical Findings / Recommended Follow-Up

Recommended Action:

Exam Date:

Occupational Health Notes

Applicant Name:

Signature:

Date:

What the HR TB Questionnaire Is and When It's Used

The HR TB Questionnaire is a standardized employee health screening form used to document tuberculosis exposure risk, prior TB diagnosis or treatment, and recent testing. Employers use it as part of pre-employment screening, periodic occupational-health surveillance, or when workplace exposure is suspected. The form collects factual medical history, test dates and results, vaccination history, and consent for testing or referral. Completed questionnaires support clinical decisions, occupational clearance determinations, and required notifications to occupational health units or public health authorities while helping maintain compliance with privacy rules.

Why a Clear HR TB Questionnaire Matters for Employers

A well-designed HR TB Questionnaire documents risk factors, speeds clinical triage, and creates a consistent record for workplace health decisions while supporting privacy and reporting obligations.

Who Typically Completes and Reviews the HR TB Questionnaire

The questionnaire is completed by the employee or applicant and reviewed by occupational health staff or designated HR personnel before placement decisions.

Employees and applicants complete personal health history, prior TB tests, and symptom screening prior to clinical evaluation.
Occupational health clinicians review responses, order tests (PPD/IGRA), and document clearance or referral for treatment.
HR or hiring managers receive only clearance status and administrative notes consistent with privacy rules; they do not receive detailed health records.

Maintain separation of medical records from personnel files and limit access per HIPAA and employer policy.

Primary Roles Involved

Occupational Health Nurse

Reviews completed questionnaires, determines need for testing, documents clinical follow-up, and communicates clearance results to HR while maintaining medical record confidentiality in accordance with HIPAA.

HR Manager

Collects administrative forms, tracks completion status, and coordinates accommodations or work restrictions based on occupational health clearance while avoiding unnecessary access to clinical details.

Essential Data Elements to Collect

Employee Name: Full legal name

Date of Birth: MM/DD/YYYY

TB Exposure: Recent known exposure

Test Type: PPD or IGRA

Test Date: MM/DD/YYYY

Signature: Signed and dated

Core Components of a Professional HR TB Questionnaire

A complete form combines clear screening questions, test and vaccination history, consent language, provider sections, and an electronic signature area so medical personnel can act without delay.

Screening Questions

Concise yes/no items for current cough, fever, night sweats, weight loss, recent TB exposure, and prior TB treatment; clear logic reduces unnecessary testing and guides clinical follow-up.

Testing History

Fields for prior PPD or IGRA dates, results, and chest X-ray history that enable clinicians to interpret new test results in context and avoid duplicate testing.

Vaccination Record

Space to record prior BCG vaccination and approximate date, since BCG history can affect PPD interpretation and subsequent clinical decisions.

Consent and Privacy

Explicit language describing why the data is collected, who will access medical information, and how it will be stored, addressing HIPAA privacy considerations and consent for testing.

Provider Findings

A clinician section for test interpretation, recommended treatment or referral, and clearance status for work that creates a single authoritative medical summary.

Signature and Date

Signature blocks for the employee and reviewer with date stamps and method of signing (electronic or handwritten) to support attribution and retention requirements.

Step-by-Step: Completing the HR TB Questionnaire

Follow these sequential steps to ensure the form is complete, accurate, and routed to the right clinical reviewer.

01

Gather ID: Confirm employee identity before entry
02

Complete Screening: Answer all symptom and exposure items
03

Attach Tests: Upload prior test reports or x-rays
04

Sign and Route: Sign, date, and send to occupational health

How to Configure an Online Completion Workflow

Typical online workflows reduce friction: collect data, require key fields, route to clinician, and store securely with restricted access.

Field	Configuration
Required Fields	Mark name, DOB, symptom checklist, signature required
Conditional Logic	Show test-order section if exposure or symptoms are yes
Reviewer Routing	Auto-route to occupational health on completion
Storage Location	Save to secure medical records repository

Where Completed Questionnaires Should Be Sent

Route completed forms to the appropriate clinical and administrative recipients for review, documentation, and any required reporting.

Occupational Health: Primary clinical reviewer for clearance and testing
HR Administration: Receives clearance status only; no detailed medical data
Public Health: Report confirmed active TB cases per jurisdictional rules
Employee Copy: Provide redacted confirmation of clearance when requested

Digital Submission and File Format Guidance

Use secure PDF or DOCX formats and a platform that preserves audit trails and access controls for medical information.

Accepted Formats: PDF, DOCX
Integrations: Works with HRIS and EHR connectors
Authentication: Email or stronger MFA for signer verification

Ensure the chosen platform supports secure storage, export to medical record systems, and role-based access to protect PHI.

Risks and Consequences of Incorrect or Missing Questionnaires

HIPAA Exposure: Unauthorized PHI disclosure risk

OSHA Citations: Workplace exposure violations possible

Delayed Care: Missed diagnosis or late treatment

Employment Liability: Potential negligence claims

Public Health Reporting: Failure to report active TB

Data Integrity: Incomplete records hinder investigations

Timing Considerations and Typical Deadlines

Certain actions have short, specific timing: testing windows, result review, and mandatory reporting should be handled promptly.

Pre-Employment Screening:

Complete questionnaire before first day of work

PPD Reading Window:

Read at 48–72 hours after placement

IGRA Turnaround:

Lab results typically available in 1–3 business days

Reporting Active TB:

Report to public health immediately per state rules

Follow-up Testing:

Schedule confirmatory testing within recommended clinical intervals

Real-World Examples of HR TB Questionnaire Use

These scenarios show how the questionnaire supports clinical decisions and operational needs in different work settings.

Healthcare Clinic — Employee Screening

A new nurse completes the HR TB Questionnaire prehire to document prior IGRA and BCG history.

Occupational health orders a repeat IGRA due to unknown test date.
The clinic documents clearance for patient care and retains the medical record separately from the employee personnel file, reducing administrative delays.

Construction Contractor — Site Clearance

Multiple subcontractors onsite required screening during a reported exposure at a project site.

Workers complete the questionnaire and are routed to a mobile clinic for IGRA testing.
Results and clinic recommendations are recorded, and only clearance status is shared with site supervisors to maintain privacy while protecting onsite safety.

eSignature Pricing and Feature Comparison

Compare common vendor entry prices and key capabilities for handling HR medical questionnaires and eSignature workflows.

	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	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
Envelope Cap	No cap	100 envelopes/user/year	Varies	Varies	Varies

FAQs and Troubleshooting for the HR TB Questionnaire

Answers to common operational and legal questions about completing, routing, and storing HR TB Questionnaires in the United States.

Need help? Contact support

Can this form be signed electronically?
Yes. Electronic signatures are legally valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided intent, consent, attribution, and record retention requirements are satisfied.
Is patient consent required?
Yes. Use clear consent language if the questionnaire triggers testing or data sharing; for consumer-facing health services ESIGN consumer disclosure requirements apply.
How should I store completed forms?
Store completed medical questionnaires separately from personnel files with access controls. Follow HIPAA retention guidance and applicable state retention rules.
When must active TB be reported?
Confirmed active TB must be reported to the local public health authority immediately, per state reporting requirements and public health statutes.
What if an employee refuses to complete it?
Document refusal, assess workplace risk, consult occupational health and legal counsel for accommodation and public health obligations.
Can HR see detailed medical answers?
No. Share only work-relevant clearance status with HR; detailed clinical information should remain with medical staff to comply with HIPAA privacy protections.

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