Get (tb) Health Assessment Form - Ucsb Student Health - University Of ...

Completing the (TB) Health Assessment Form is an essential step for students at the University of California, Santa Barbara, who are required to undergo tuberculosis testing prior to enrollment. This guide offers detailed, step-by-step instructions on how to accurately fill out the form online to ensure a smooth submission process.

Follow the steps to complete the form successfully

1. Press the ‘Get Form’ button to obtain the (TB) Health Assessment Form and open it in your editor of choice.
2. Begin by filling in your name and date of birth in the designated fields. Ensure that your Perm# is also included for identification purposes.
3. Answer all six history questions honestly. For each question, check 'Yes' or 'No' and provide comments where prompted. This section is crucial for evaluating your TB risk.
4. For the medication section, specify any treatment for latent tuberculosis, including the start and end dates if applicable, and ensure you attach any available documentation.
5. If you have had close contact with someone known or suspected to have active TB, provide the date of last contact.
6. Indicate whether you exhibit any signs or symptoms of active TB disease, such as a persistent cough or unexplained weight loss. If so, you will need to evaluate further.
7. Complete the testing section by choosing either a TB Blood Test (IGRA) or a Tuberculin Skin Test (TST). Make sure to fill in the date obtained and result.
8. If applicable, record the details of your chest x-ray including the date, result, and attach the written radiology report.
9. If your chest x-ray raised concerns for TB, note the results of the 3 sputum tests, providing the date and results for each.
10. Finally, have a licensed healthcare provider sign and print their name and details in the designated areas. Ensure the form is complete before submission.
11. Save your changes, and choose to download or print the completed form. You can upload it on Gateway, email it to the provided address, or send it via fax.

Complete your (TB) Health Assessment Form online today to ensure your enrollment at UCSB!