California School Employee Tuberculosis (TB) Risk Assessment Questionnaire - Certificate of Completion - Tuberculosis Risk Assessment and/or Examination

Sep 18, 2026

California School Employee Tuberculosis (TB) Risk Assessment Questionnaire and the Certificate of Completion support California job-related requirements for pre-K, K-12 schools, and community college employees, volunteers, and contractors. The questionnaire screens for TB disease risk factors and instructs when TB testing and evaluation are needed, including guidance for excluding active TB disease before latent TB infection (LTBI) treatment. The certificate confirms completion of risk assessment and/or examination and records provider authorization and patient findings.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages10

Reading Time25 min

AccessFree to download

California School Employee Tuberculosis (TB) Risk Assessment Questionnaire

History of Tuberculosis Disease or Infection

TB testing is recommended

Certificate of Completion

Tuberculosis Risk Assessment and/or Examination

Background

Testing for latent TB infection (LTBI)

# California School Employee Tuberculosis (TB)Risk Assessment Questionnaire (for pre-K,K-12 schools and community college employees,volunteers and contractors) ·Use of this questionnaire is required by California Education Code sections 49406 and 87408.6,and Heath andSafety Code sections 1597.055 and 121525-121555.^ ·The purpose of this tool is to identify aduts with infectious tuberculosis (TB)to prevent them from spreadingdisease. ·Do not repeat testing unless there are new risk factors since the last negative test ● Do not treat for latent TB infection(LTBl)until active TB disease has been excluded: For individuals with signs or symptoms oi TB disease or abnormal chest x-ray consistent with TB disease,evaluate for acive TB diseasewith a chest ×-ray,symptom screen,and if indicated,spufum AFB smears cuitures and nuceic acid ampifcation testing.A negative fuberculin skin test (TST)or interferon gamma release assay (IGRA)does not rule out active TB disease. Name of Person Assessed for TB Risk Factors: Date of Birth: Assessment Date: | History of Tuberculosis Disease or Infection(Check appropriate box below) | | --- | | □ Yes
● if there is a documented history of positive TB test or TB disease,then a symptom review and chest x-ray(if none performed in
the previous 6 months)should be performed at initial hire by a physician,physician assistant,or nurse practitioner.If thex-ray
does not have evidence of TB,the person is no longer required to submit to a TB risk assessment or repeat chest x-rays. | | □ No (Assess for Risk Factors for Tuberculosis using box below) | | TB testing is recommended if any of the 3 boxes below are checked | | --- | | □ One or more sign(s)or symptom(s)of TB disease
TB symptoms include prolonged cough.coughing uD bloo0.fever.niaht sweats.weioht loss.or excesive faiquE | | □ Birth.travel.or residence in a countrv with an elevated TB rate for at least 1 montl
·Includes countries other than the United States,Canada,Australia,New Zealand,or Western and North European countries.
Interferon gamma release assay (IGRA)is preferred over tuberculin skin test(TST)for non-US-born persons. | | □ Close contact to someone with infectious TB disease during lifetime | | Treat for LTBIif TB test result is positive and active TB disease is ruled out | ^The law requires that a health care provider administer this questionaire.A health care provider,as defined fo this purpose,is anyorganization,facliy,institution or person licensed,certified or otherwise authorized or permited by state law to deliver or furnish healthservices.A Cerificate of Completion should be completed after screening is completed (page 3). 5/06/20 ## Certificate of CompletionTuberculosis Risk Assessment and/or Examination To satisfy job-related requirements in the California Education Code,Sections 49406 and87408.6and the California Health and Safety Code,Sections 1597.055,121525,121545and121555. First and Last Name of the person assessed and/or examined: mo./ day/ Date of assessment and/or examination: yr mo./ day/ Date of Birth: yr. The above named patient has submitted to a tuberculosis risk assessment.The patientdoes not have risk factors,or if tuberculosis risk factors were identified,the patient hasbeen examined and determined to be free of infectious tuberculosis. X Signature of Health Care Provider completing the risk assessment and/or examination Please print,place label or stamp with Health Care Provider Name and Address (includeNumber,Street,City,State,and Zip Code): 5/06/20 (for pre-K,K-12 schools and community college employees,volunteers and contractors) Background California law requires that schooi staff working with childre

FAQs

Who is required to complete the California School Employee TB risk assessment questionnaire and certificate of completion?

Pre-K, K-12 school and community college employees, volunteers, and contractors are required to complete the TB risk assessment questionnaire and certificate of completion under California law referenced in the form.

When is TB testing recommended according to the questionnaire?

TB testing is recommended if the person has one or more TB signs or symptoms, has birth/travel/residence in a country with an elevated TB rate for at least one month, or has close contact with someone with infectious TB disease during their lifetime.

Why must active TB disease be excluded before treating latent TB infection (LTBI)?

The form states that LTBI treatment should not begin until active TB disease has been excluded using evaluation such as a chest x-ray, symptom screen, and, when indicated, sputum testing; a negative TST or IGRA does not rule out active TB disease.

Sep 18, 2026

Upload by Taylor Morgan