TB Questionnaire
Basic Information
Submission ID
Workflow
Last Name
Required
First Name
Required
Middle Initial
(if applicable)
Maiden Name
(if applicable)
ACC email
Required
ACC ID (eg. a2222222)
Required
Academic Information
Program
Please select...
Allied Health Sciences
Continuing Education
Dental Hygiene
Emergency Medical Services Professions
Health Information Technology
Health Sciences Academy
Medical Lab Technology
Occupational Therapy Assistant
Pharmacy Technician
Phlebotomy
Physical Therapist Assistant
Professional Nursing
Radiology
Sonography
Surgical Technology
Veterinary Technology
Vocational Nursing
Track
Please select...
Billing & Coding
Certified Nurse Aide
Dental Assistant
Medical Assistant
Medical Office Support
Nurse Re-Entry
Sterile Processing
Track
Please select...
Traditional
Mobility
RN-to-BSN
Track
Please select...
Phlebotomy
Emergency Medical Technician
Pharmacy Technician
Current Semester/Year
Please select...
Spring 2026
Summer 2026
Fall 2026
Spring 2027
Program Details
Program Admin
TB Blood Test (QFT or TSPOT) lab results must be submitted once per year or as directed by your program.
If previous
positive QFT or TSPOT, then x-ray must be completed within
90 days
of start of semester or as directed by your program.
1. Have you previously tested positive during any TB testing?
Yes
No
2. Have you been a temporary or permanent resident of ≥ 1 month in a
country with a high TB rate (any country other than the US, Canada,
Australia, New Zealand, and those in Northern Europe or Western
Europe)?
Yes
No
3. Are you currently taking or planning to take medication for
immunosuppression including human immunodeficiency virus infection,
organ transplant recipient, treatment with a TNF-alpha antagonist (e.g.,
infliximab, etanercept, or other), chronic steroids (equivalent of
prednisone ≥ 15 mg/day for ≥ 1 month) or other immunosuppressive
medication?
Yes
No
4. Have you come in close contact with someone who has had infectious
TB disease since your last TB test?
Yes
No
5. Have you had a Chronic Cough for 3 weeks or longer?
Yes
No
6. Excessive production of Sputum 3 weeks or longer?
Yes
No
7. Blood-Streaked Sputum 3 weeks or longer?
Yes
No
8. Unexplained Weight Loss?
Yes
No
9. Fever lasting over 3 to 4 weeks?
Yes
No
10. Fatigue or Tiredness lasting over 3-4 weeks?
Yes
No
11. Night Sweats over 3-4 weeks?
Yes
No
12. Shortness of Breath over the past 3-4 weeks?
Yes
No
If you answered "Yes" to any question above, please explain below.
CASE
CASE_OUTPUT
Case
Case 1
Typical Case, deposit to Box.com, no notification.
Case 3
Notification Case, deposit to Box.com, Notify Lisa Enloe with form for evaluation..
Case 2
Typical Case, deposit to Box.com, no notification.
Contact Information