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Submitted URL: https://redcap.link/TBScreen
Effective URL: https://redcap.chop.edu/surveys/?s=34YJX4JM8M
Submission: On November 11 via manual from US — Scanned from US
Effective URL: https://redcap.chop.edu/surveys/?s=34YJX4JM8M
Submission: On November 11 via manual from US — Scanned from US
Form analysis 1 forms found in the DOM
Name: form — POST /surveys/index.php?s=34YJX4JM8M
<form action="/surveys/index.php?s=34YJX4JM8M" enctype="multipart/form-data" target="_self" method="post" name="form" id="form"><input type="hidden" name="redcap_csrf_token" value="">
<div>
<script type="text/javascript">
if (typeof lang == 'undefined') {
var lang = {}
};
lang.global_143 = 'Checked';
lang.global_144 = 'Unchecked';
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<script type="text/javascript">
var missing_data_replacement_js = '______';
var piping_receiver_class_field_js = '.piping_receiver.piperec-';
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<span id="maxchecked_tag_label" class="" style="display:none;z-index:1000;" data-rc-lang="data_entry_421">Cannot select choice! The maximum number of choices has been selected.</span><span id="matrix_rank_remove_label" class="opacity75"
style="display:none;" data-rc-lang="data_entry_203">Value removed!</span>
<div id="questiontable_loading" style="display: none; visibility: visible;">
<img alt="Loading..." src="/redcap_v12.5.15/Resources/images/progress_circle.gif"> <span data-rc-lang="data_entry_64">Loading...</span>
</div>
<script type="text/javascript">
setTimeout(function() {
document.getElementById('questiontable_loading').style.visibility = 'visible';
}, 750);
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<div title="Incompatible checkbox selection" id="noneOfTheAboveDialog" class="simpleDialog "><span data-rc-lang="data_entry_518" data-rc-lang-values="eyIwIjoiXCI8YiBpZD0nbm9uZU9mVGhlQWJvdmVMYWJlbERpYWxvZyc+PFwvYj5cIiJ9">The option
"<b id="noneOfTheAboveLabelDialog"></b>" can only be selected by itself. Selecting this option will clear your previous selections for this checkbox field. Are you sure?</span></div>
<div title="Incompatible checkbox selection" id="noneOfTheAboveDialog" class="simpleDialog "><span data-rc-lang="data_entry_518" data-rc-lang-values="eyIwIjoiXCI8YiBpZD0nbm9uZU9mVGhlQWJvdmVMYWJlbERpYWxvZyc+PFwvYj5cIiJ9">The option
"<b id="noneOfTheAboveLabelDialog"></b>" can only be selected by itself. Selecting this option will clear your previous selections for this checkbox field. Are you sure?</span></div>
<table role="presentation" class="form_border container-fluid" style="display: table;" id="questiontable">
<tbody class="formtbody">
<tr class="@NOW" id="today_s_date-tr" sq_id="today_s_date">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-today_s_date">
<div data-kind="field-label">
<div data-mlm-field="today_s_date" data-mlm-type="label"> Today's Date</div>
</div>
</label></td>
<td class="data col-5"><span data-kind="field-value"><input autocomplete="new-password" aria-labelledby="label-today_s_date" class="x-form-text x-form-field date_mdy hasDatepicker calcChanged" type="text" name="today_s_date" value=""
onblur="redcap_validate(this,'','','soft_typed','date_mdy',1)" tabindex="0" onkeydown="dateKeyDown(event,'today_s_date')" fv="date_mdy" id="dp1668201788530"><img class="ui-datepicker-trigger d-print-none"
src="/redcap_v12.5.15/Resources/images/date.png" alt="Click to select a date" title="Click to select a date"></span>
<button ignore="Yes" class="jqbuttonsm ml-2 today-now-btn d-print-none ui-button ui-corner-all ui-widget" onclick="setToday('today_s_date','date_mdy');return false;"><span data-rc-lang="dashboard_32">Today</span></button><span class="df"
data-rc-lang="multilang_110">M-D-Y</span>
<div id="today_s_date_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="first_name-tr" sq_id="first_name" req="1">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-first_name">
<div data-kind="field-label">
<div data-mlm-field="first_name" data-mlm-type="label"> First Name</div>
<div class="requiredlabel" aria-label="Question required.">* <span data-rc-lang="data_entry_39">must provide value</span></div>
</div>
</label></td>
<td class="data col-5"><span data-kind="field-value"><input autocomplete="new-password" aria-required="true" aria-labelledby="label-first_name" class="x-form-text x-form-field " type="text" name="first_name" value="" tabindex="0"></span>
<div id="first_name_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="last_name-tr" sq_id="last_name" req="1">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-last_name">
<div data-kind="field-label">
<div data-mlm-field="last_name" data-mlm-type="label"> Last Name</div>
<div class="requiredlabel" aria-label="Question required.">* <span data-rc-lang="data_entry_39">must provide value</span></div>
</div>
</label></td>
<td class="data col-5"><span data-kind="field-value"><input autocomplete="new-password" aria-required="true" aria-labelledby="label-last_name" class="x-form-text x-form-field " type="text" name="last_name" value="" tabindex="0"></span>
<div id="last_name_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="best_phone_to_be_reached-tr" sq_id="best_phone_to_be_reached" req="1">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-best_phone_to_be_reached">
<div data-kind="field-label">
<div data-mlm-field="best_phone_to_be_reached" data-mlm-type="label"> Best phone # to be reached: </div>
<div class="requiredlabel" aria-label="Question required.">* <span data-rc-lang="data_entry_39">must provide value</span></div>
</div>
</label></td>
<td class="data col-5"><span data-kind="field-value"><input autocomplete="new-password" aria-required="true" aria-labelledby="label-best_phone_to_be_reached" class="x-form-text x-form-field " type="text" name="best_phone_to_be_reached"
value="" onblur="redcap_validate(this,'','','soft_typed','phone',1)" tabindex="0" fv="phone"></span>
<div id="best_phone_to_be_reached_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="volunteer_id-tr" sq_id="volunteer_id">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-volunteer_id">
<div data-kind="field-label">
<div data-mlm-field="volunteer_id" data-mlm-type="label"> Volunteer ID #:</div>
</div>
</label></td>
<td class="data col-5"><span data-kind="field-value"><input autocomplete="new-password" aria-labelledby="label-volunteer_id" class="x-form-text x-form-field " type="text" name="volunteer_id" value="" tabindex="0"></span>
<div id="volunteer_id_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="department_or_program-tr" sq_id="department_or_program">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-department_or_program">
<div data-kind="field-label">
<div data-mlm-field="department_or_program" data-mlm-type="label"> Department or program: </div>
</div>
</label></td>
<td class="data col-5"><span data-kind="field-value"><input autocomplete="new-password" aria-labelledby="label-department_or_program note-department_or_program" class="x-form-text x-form-field " type="text" name="department_or_program"
value="" tabindex="0"></span>
<div id="note-department_or_program" class="note" data-mlm-field="department_or_program" data-mlm-type="note" aria-hidden="true">i.e. Child Life, Bedside Buddy, NICU, Pet Therapy, Wawa cart, etc.</div>
<div id="department_or_program_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="email_address-tr" sq_id="email_address" req="1">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-email_address">
<div data-kind="field-label">
<div data-mlm-field="email_address" data-mlm-type="label"> Email address:</div>
<div class="requiredlabel" aria-label="Question required.">* <span data-rc-lang="data_entry_39">must provide value</span></div>
</div>
</label></td>
<td class="data col-5"><span data-kind="field-value"><input autocomplete="new-password" aria-required="true" aria-labelledby="label-email_address" class="x-form-text x-form-field " type="text" name="email_address" value=""
onblur="redcap_validate(this,'','','soft_typed','email',1)" tabindex="0" fv="email"></span>
<div id="email_address_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="category_1_if_any_of_the_f-sh-tr" sq_id="{}" style="display: table-row;">
<td class="header toolbar" colspan="3">
<div data-mlm-field="category_1_if_any_of_the_f" data-mlm-type="header">Category One</div>
</td>
</tr>
<script type="text/javascript">
$(function() {
noneOfTheAboveAlert('category_1_if_any_of_the_f', '4', '1,2,3', window.lang.data_entry_417, window.lang.global_53);
});
</script>
<tr class="@NONEOFTHEABOVE" id="category_1_if_any_of_the_f-tr" sq_id="category_1_if_any_of_the_f" req="1">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-category_1_if_any_of_the_f">
<div data-kind="field-label">
<div data-mlm-field="category_1_if_any_of_the_f" data-mlm-type="label"> Category 1: if any of the following are true check the appropriate boxes.</div>
<div class="requiredlabel" aria-label="Question required.">* <span data-rc-lang="data_entry_39">must provide value</span></div>
</div>
</label></td>
<td class="data col-5"><span data-kind="field-value">
<div class="choicevert" onclick=""><input type="checkbox" aria-labelledby="label-category_1_if_any_of_the_f label-category_1_if_any_of_the_f-1" tabindex="0" onchange="clean_datetime(this,'');doBranching('category_1_if_any_of_the_f');"
id="id-__chk__category_1_if_any_of_the_f_RC_1" name="__chkn__category_1_if_any_of_the_f" code="1" onclick="checkboxClick('category_1_if_any_of_the_f','1',this,event,0);"><input type="hidden" value=""
name="__chk__category_1_if_any_of_the_f_RC_1"> <label id="label-category_1_if_any_of_the_f-1" class="mc" for="id-__chk__category_1_if_any_of_the_f_RC_1" data-mlm-field="category_1_if_any_of_the_f" data-mlm-type="enum"
data-mlm-value="1">History of a previous positive TB skin or blood test</label></div>
<div class="choicevert" onclick=""><input type="checkbox" aria-labelledby="label-category_1_if_any_of_the_f label-category_1_if_any_of_the_f-2" tabindex="0" onchange="clean_datetime(this,'');doBranching('category_1_if_any_of_the_f');"
id="id-__chk__category_1_if_any_of_the_f_RC_2" name="__chkn__category_1_if_any_of_the_f" code="2" onclick="checkboxClick('category_1_if_any_of_the_f','2',this,event,0);"><input type="hidden" value=""
name="__chk__category_1_if_any_of_the_f_RC_2"> <label id="label-category_1_if_any_of_the_f-2" class="mc" for="id-__chk__category_1_if_any_of_the_f_RC_2" data-mlm-field="category_1_if_any_of_the_f" data-mlm-type="enum"
data-mlm-value="2">Persistent cough with sputum AND coughing up blood</label></div>
<div class="choicevert" onclick=""><input type="checkbox" aria-labelledby="label-category_1_if_any_of_the_f label-category_1_if_any_of_the_f-3" tabindex="0" onchange="clean_datetime(this,'');doBranching('category_1_if_any_of_the_f');"
id="id-__chk__category_1_if_any_of_the_f_RC_3" name="__chkn__category_1_if_any_of_the_f" code="3" onclick="checkboxClick('category_1_if_any_of_the_f','3',this,event,0);"><input type="hidden" value=""
name="__chk__category_1_if_any_of_the_f_RC_3"> <label id="label-category_1_if_any_of_the_f-3" class="mc" for="id-__chk__category_1_if_any_of_the_f_RC_3" data-mlm-field="category_1_if_any_of_the_f" data-mlm-type="enum"
data-mlm-value="3">Persistent cough with sputum AND excessive sweating at night</label></div>
<div class="choicevert" onclick=""><input type="checkbox" aria-labelledby="label-category_1_if_any_of_the_f label-category_1_if_any_of_the_f-4" tabindex="0" onchange="clean_datetime(this,'');doBranching('category_1_if_any_of_the_f');"
id="id-__chk__category_1_if_any_of_the_f_RC_4" name="__chkn__category_1_if_any_of_the_f" code="4" onclick="checkboxClick('category_1_if_any_of_the_f','4',this,event,0);"><input type="hidden" value=""
name="__chk__category_1_if_any_of_the_f_RC_4"> <label id="label-category_1_if_any_of_the_f-4" class="mc" for="id-__chk__category_1_if_any_of_the_f_RC_4" data-mlm-field="category_1_if_any_of_the_f" data-mlm-type="enum"
data-mlm-value="4">Not applicable</label></div>
</span>
<div class="space"></div>
<div id="category_1_if_any_of_the_f_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="you_will_be_promoted_to_an-tr" sq_id="you_will_be_promoted_to_an" style="display: none;">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-11" colspan="2">
<div data-kind="field-label">
<div data-mlm-field="you_will_be_promoted_to_an" data-mlm-type="label"> You will be prompted to the Annual TB Review Questionnaire form. </div>
</div>
</td>
</tr>
<tr id="catagory_2-sh-tr" sq_id="{}" style="display: table-row;">
<td class="header toolbar" colspan="3">
<div data-mlm-field="catagory_2" data-mlm-type="header">Category Two</div>
</td>
</tr>
<script type="text/javascript">
$(function() {
noneOfTheAboveAlert('catagory_2', '12', '8,9,10,11', window.lang.data_entry_417, window.lang.global_53);
});
</script>
<tr class="@NONEOFTHEABOVE" id="catagory_2-tr" sq_id="catagory_2" req="1">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-catagory_2">
<div data-kind="field-label">
<div data-mlm-field="catagory_2" data-mlm-type="label"> Category 2: if ANY of the following apply since your last TB screening AND you have never had a positive TB skin or blood test:</div>
<div class="requiredlabel" aria-label="Question required.">* <span data-rc-lang="data_entry_39">must provide value</span></div>
</div>
</label></td>
<td class="data col-5"><span data-kind="field-value">
<div class="choicevert" onclick=""><input type="checkbox" aria-labelledby="label-catagory_2 label-catagory_2-8" tabindex="0" onchange="clean_datetime(this,'');doBranching('catagory_2');" id="id-__chk__catagory_2_RC_8"
name="__chkn__catagory_2" code="8" onclick="checkboxClick('catagory_2','8',this,event,0);"><input type="hidden" value="" name="__chk__catagory_2_RC_8"> <label id="label-catagory_2-8" class="mc" for="id-__chk__catagory_2_RC_8"
data-mlm-field="catagory_2" data-mlm-type="enum" data-mlm-value="8">Contact with any person with known active tuberculosis disease at home, work, or any other setting</label></div>
<div class="choicevert" onclick=""><input type="checkbox" aria-labelledby="label-catagory_2 label-catagory_2-9" tabindex="0" onchange="clean_datetime(this,'');doBranching('catagory_2');" id="id-__chk__catagory_2_RC_9"
name="__chkn__catagory_2" code="9" onclick="checkboxClick('catagory_2','9',this,event,0);"><input type="hidden" value="" name="__chk__catagory_2_RC_9"> <label id="label-catagory_2-9" class="mc" for="id-__chk__catagory_2_RC_9"
data-mlm-field="catagory_2" data-mlm-type="enum" data-mlm-value="9">Family member or household contact with newly positive TB skin or blood test</label></div>
<div class="choicevert" onclick=""><input type="checkbox" aria-labelledby="label-catagory_2 label-catagory_2-10" tabindex="0" onchange="clean_datetime(this,'');doBranching('catagory_2');" id="id-__chk__catagory_2_RC_10"
name="__chkn__catagory_2" code="10" onclick="checkboxClick('catagory_2','10',this,event,0);"><input type="hidden" value="" name="__chk__catagory_2_RC_10"> <label id="label-catagory_2-10" class="mc" for="id-__chk__catagory_2_RC_10"
data-mlm-field="catagory_2" data-mlm-type="enum" data-mlm-value="10">Time spent in a correctional facility, homeless shelter, or refugee shelter</label></div>
<div class="choicevert" onclick=""><input type="checkbox" aria-labelledby="label-catagory_2 label-catagory_2-11" tabindex="0" onchange="clean_datetime(this,'');doBranching('catagory_2');" id="id-__chk__catagory_2_RC_11"
name="__chkn__catagory_2" code="11" onclick="checkboxClick('catagory_2','11',this,event,0);"><input type="hidden" value="" name="__chk__catagory_2_RC_11"> <label id="label-catagory_2-11" class="mc" for="id-__chk__catagory_2_RC_11"
data-mlm-field="catagory_2" data-mlm-type="enum" data-mlm-value="11">Travel to any country (other than the United States, Canada, Australia, New Zealand, and those in Northern Europe or Western Europe) in which you delivered medical
care OR had temporary or permanent residence of ≥1 month</label></div>
<div class="choicevert" onclick=""><input type="checkbox" aria-labelledby="label-catagory_2 label-catagory_2-12" tabindex="0" onchange="clean_datetime(this,'');doBranching('catagory_2');" id="id-__chk__catagory_2_RC_12"
name="__chkn__catagory_2" code="12" onclick="checkboxClick('catagory_2','12',this,event,0);"><input type="hidden" value="" name="__chk__catagory_2_RC_12"> <label id="label-catagory_2-12" class="mc" for="id-__chk__catagory_2_RC_12"
data-mlm-field="catagory_2" data-mlm-type="enum" data-mlm-value="12">Not applicable</label></div>
</span>
<div class="space"></div>
<div id="catagory_2_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="you_will_be_prompted_to_ta-tr" sq_id="you_will_be_prompted_to_ta" style="display: none;">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-11" colspan="2">
<div data-kind="field-label">
<div data-mlm-field="you_will_be_prompted_to_ta" data-mlm-type="label"> You will be prompted to the Annual TB Review Questionnaire and be able to print the CHOP TB PPD Skin test form for Occ. Health or your PCP-primary care physician.
</div>
</div>
</td>
</tr>
<tr id="no_further_action_is_requi-sh-tr" sq_id="{}" style="display: none;">
<td class="header toolbar" colspan="3">
<div data-mlm-field="no_further_action_is_requi" data-mlm-type="header">Category Three</div>
</td>
</tr>
<tr id="no_further_action_is_requi-tr" sq_id="no_further_action_is_requi" style="display: none;">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-11" colspan="2">
<div data-kind="field-label">
<div data-mlm-field="no_further_action_is_requi" data-mlm-type="label"> Category 3: No further action is required if none of the questions are applicable to you.<br> Please press submit you have completed the Annual PPD Volunteer
Requirement. </div>
</div>
</td>
</tr>
<tr class="@HIDDEN-SURVEY" id="volunteer_staff_name-tr" sq_id="volunteer_staff_name">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-volunteer_staff_name">
<div data-kind="field-label">
<div data-mlm-field="volunteer_staff_name" data-mlm-type="label"> Volunteer Staff Name:</div>
</div>
</label></td>
<td class="data col-5"><span data-kind="field-value"><input autocomplete="new-password" aria-labelledby="label-volunteer_staff_name note-volunteer_staff_name" class="x-form-text x-form-field " type="text" name="volunteer_staff_name"
value="" tabindex="0"></span>
<div id="note-volunteer_staff_name" class="note" data-mlm-field="volunteer_staff_name" data-mlm-type="note" aria-hidden="true">Enter First and Last Name</div>
<div id="volunteer_staff_name_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr class="@HIDDEN-SURVEY" id="volunteer_services-tr" sq_id="volunteer_services">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-volunteer_services">
<div data-kind="field-label">
<div data-mlm-field="volunteer_services" data-mlm-type="label"> Volunteer Services:</div>
</div>
</label></td>
<td class="data col-5"><span data-kind="field-value">
<div class="choicevert" onclick=""><input type="checkbox" aria-labelledby="label-volunteer_services label-volunteer_services-1" tabindex="0" id="id-__chk__volunteer_services_RC_1" name="__chkn__volunteer_services" code="1"
onclick="checkboxClick('volunteer_services','1',this,event,0);"><input type="hidden" value="" name="__chk__volunteer_services_RC_1"> <label id="label-volunteer_services-1" class="mc" for="id-__chk__volunteer_services_RC_1"
data-mlm-field="volunteer_services" data-mlm-type="enum" data-mlm-value="1">Entered into VSys</label></div>
<div class="choicevert" onclick=""><input type="checkbox" aria-labelledby="label-volunteer_services label-volunteer_services-2" tabindex="0" id="id-__chk__volunteer_services_RC_2" name="__chkn__volunteer_services" code="2"
onclick="checkboxClick('volunteer_services','2',this,event,0);"><input type="hidden" value="" name="__chk__volunteer_services_RC_2"> <label id="label-volunteer_services-2" class="mc" for="id-__chk__volunteer_services_RC_2"
data-mlm-field="volunteer_services" data-mlm-type="enum" data-mlm-value="2">Scanned form into VSys</label></div>
</span>
<div class="space"></div>
<div id="volunteer_services_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr class="@HIDDEN-SURVEY" id="comments2-tr" sq_id="comments2">
<td class="labelrc questionnum col-1" valign="top"></td>
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Gtshz89CWZsSELJUrDGKTxJCBCwhkncAha5KWEY2G3cAS7Q6YWCEv4ULtbSohDf4q7sIS7mQI3sz7RjyybNQFSiXS
CHOP ANNUAL VOLUNTEER CHOP TUBERCULOSIS RISK ASSESSMENT SCREENING FORM
A A A
If you answer questions that place you in category 1 or 2 (see below), you will
be prompted to start the next TB Questionnaire after you click 'submit'.
If none of the questions are applicable to you on the initial survey this is a
considered a category 3, meaning you will not need to complete any further
questions and you have completed the Volunteer Annual PPD requirement.
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your previous selections for this checkbox field. Are you sure?
The option "" can only be selected by itself. Selecting this option will clear
your previous selections for this checkbox field. Are you sure?
Today's Date
TodayM-D-Y
First Name
* must provide value
Last Name
* must provide value
Best phone # to be reached:
* must provide value
Volunteer ID #:
Department or program:
i.e. Child Life, Bedside Buddy, NICU, Pet Therapy, Wawa cart, etc.
Email address:
* must provide value
Category One
Category 1: if any of the following are true check the appropriate boxes.
* must provide value
History of a previous positive TB skin or blood test
Persistent cough with sputum AND coughing up blood
Persistent cough with sputum AND excessive sweating at night
Not applicable
You will be prompted to the Annual TB Review Questionnaire form.
Category Two
Category 2: if ANY of the following apply since your last TB screening AND you
have never had a positive TB skin or blood test:
* must provide value
Contact with any person with known active tuberculosis disease at home, work, or
any other setting
Family member or household contact with newly positive TB skin or blood test
Time spent in a correctional facility, homeless shelter, or refugee shelter
Travel to any country (other than the United States, Canada, Australia, New
Zealand, and those in Northern Europe or Western Europe) in which you delivered
medical care OR had temporary or permanent residence of ≥1 month
Not applicable
You will be prompted to the Annual TB Review Questionnaire and be able to print
the CHOP TB PPD Skin test form for Occ. Health or your PCP-primary care
physician.
Category Three
Category 3: No further action is required if none of the questions are
applicable to you.
Please press submit you have completed the Annual PPD Volunteer Requirement.
Volunteer Staff Name:
Enter First and Last Name
Volunteer Services:
Entered into VSys
Scanned form into VSys
Comments:
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Submit
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