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Get CA TB Screening Form 2015-2024

R school. (employer or school): __________________________________________________  Other reason: __________________________________________________________________________________ PLEASE ANSWER THE FOLLOWING QUESTIONS:  Yes No If Yes  Were you born or raised outside the USA? Country of Birth ____________________ Year entered the USA __________ day / mo / yr Never had Don’t know Yes No If Yes   Have any medical conditions? If yes, list: ___.

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