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TB Questionnaire

Questions About Your Child and Tuberculosis (TB)

 
 

We need your help to find out if your child has been exposed to the disease tuberculosis, also known as TB.

TB is caused by germs. It is usually spread to another person by coughing or sneezing. A person can have TB germs in their body but not have active TB disease. TB can be prevented and treated. Your answers to the questions below will let us know if your child might have been exposed to TB. If your answers show your child might have picked up the TB germs, we will want to give him or her a TB skin test. The skin test is not a vaccination. It will not prevent TB. It will only let us know if your child has the TB germs.

 

Make a selection that matches your answer:

 

1. Has your child been tested for TB?

 
 

2. Have you ever been told that your child had a positive TB skin test?

 
 

3a. TB can cause fever that can last days or weeks. It can cause weight loss, a bad cough (lasting over two weeks), or coughing up blood. Has your child been around anyone with any of these problems?

 

3b. Has your child been around anyone sick with TB?

 

3c. Has your child ever had any of these problems or do they have them now?

 
 

4. Was your child born in another part of the world like Mexico or Latin America, the Caribbean, Africa, Eastern Europe, or Asia?

 
 

5. Has your child been to Mexico or any other country in Latin America, the Caribbean, Africa, Eastern Europe, or Asia for more than 3 weeks?

 
 

6a. Do you know if your child has spent more than 3 weeks with anyone who: Uses needles for drug use?

 

6b. Has AIDS?

 

6c. Was or is in jail or prison?

 

6d. Has just come to the United States from another country?

* Required field