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Get Advocate Occupational and Employee Health Centers TB Test/Health History Questionnaire

Print) Facility_________________________________________Dept Rotating With______________________DOB_____/_____/_____ REASON FOR SCREENING (Test or Questionnaire) J J Pre-Placement Annual / Semi-annual J J Initial Exposure Post Exposure Baseline J J Post Exposure Follow-up Other _______________ FIT TESTING (for those who have been fit tested for the TB mask) Since your last fit test for the TB mask or respirator, check all that apply which may have altered the fit of your mask: J New scar.

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