LGSUHSD TB RISK ASSESSMENT 
Please complete this short online form regarding your exposure to TB risk factors.  Your responses will be transmitted securely to Lisa Tripp, District Nurse for LGSUHSD.  Nurse Lisa will contact you to review the form, and advise you if anything further is needed for your TB clearance.
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Email *
What is today's date? *
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DD
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What is your first and last name? *
What is your phone number? *
What is your birthdate? *
In what capacity will you be working for LGSUHSD? *
Are you being onboarded as a NEWLY HIRED Staff member with LGSUHSD? *
Have you ever had a documented positive TB test or a confirmed case of tuberculosis disease? *
Have you experienced any of the following symptoms of TB:  prolonged cough, coughing up blood, fever, night sweats, weight loss, or excessive fatigue. *
Have you had close contact to someone with infectious TB disease during your lifetime? *
In what country were you born? *
Were you born in or have you visited or lived in a country other than the United States, Canada, Australia, New Zealand, or Western and North European countries for more than one month? *
If you answered YES to the above question, please name the country and the year that you last lived/visited there.  Please also include the length of your last stay in that county.
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