TB RISK QUESTIONNAIRE

TUBERCULOSIS RISK QUESTIONNAIRE FOR MONTSERRAT STUDENTS

Circle Yes or No to each question: 1. To the best of your knowledge have you ever had close contact with anyone who was sick with tuberculosis (TB)? YES or NO 2. Were you born in one of the countries listed below? YES or NO 3. Have you traveled or lived for more than one month in one or more of the countries listed below? YES or NO

COUNTRIES WITH HIGH RATES OF TUBERCULOSIS (TB)*

Afghanistan SAR Guyana Mauritius Rwanda Angola China, Macao SAR Haiti Micronesia Sao Tome & Principe Arab Rep. Colombia Honduras Moldova, Rep. Senegal Armenia Comoros India Mongolia Sierra Leone Azerbaijan Congo Indonesia Morocco Solomon Islands Bahamas Congo, DR Iran Mozambique Somalia Bahrain Cote d’Ivoire Iraq Myanmar South Africa Bangladesh Croatia Kazakhstan Namibia Sri Lanka Belarus Darussalam Kenya Nepal Sudan Benin Djibouti Kiribati New Caledonia Suriname Bhutan Dominican Rep. Korea, DPR Nicaragua Swaziland Bolivia Ecuador Korea, Rep. Niger Syrian Bosnia & El Salvador Kyrgyzstan Nigeria Tajikistan Herzegovina Equatorial Guinea Lao PDR Niue Tanzania, UR Botswana Eritrea Latvia Northern Mariana Thailand Brazil Estonia Lesotho Islands Togo Brunei Ethiopia Liberia Pakistan Tokelau Burkina Faso Lithuania Palau Turkmenistan Burundi Gabon Macedonia, TFYR Panama Uganda Cambodia Gambia Madagascar Papua New Guinea Ukraine Cameroon Georgia Malawi Paraguay Uzbekistan Cape Verde Ghana Malaysia Peru Vanuatu Central African Rep. Guam Maldives Philippines Vietnam Chad Guatemala Mali Portugal Yemen China Guinea Marshall Islands Romania Zambia China, Hong Kong Guinea-Bissau Mauritania Russian Federation Zimbabwe

If the answer to any of the above questions is YES, the Massachusetts Department of Public Health strongly recommends that you have a tuberculin skin test to check for latent tuberculosis infection. If the answer to all of the above questions is NO, a tuberculin skin test should not be done. Please note: If you have had a positive tuberculin skin test in the past, you do not need another test.