Tuberculosis Screening Form Header Image

Tuberculosis (TB) Screening Questionnaire

Name*
1. Were you born in one of the countries or territories listed below that have a high incidence of active TB disease?*
Countries/Territories with high incidence of active TB disease.
2. Have you had frequent or prolonged visits to one or more of the countries or territories listed below with a high prevalence of TB disease?*
Which countries have you had frequent or prolonged visits too?
Countries/Territories with high incidence of active TB disease.

Countries/Territories with high incidence of active TB disease

Angola
Anguilla
Argentina
Armenia
Azerbaijan
Bangladesh
Belarus
Belize
Benin
Bhutan
Bolivia (Plurinational State of) 
Bosnia and Herzegovina 
Botswana
Brazil
Brunei Darussalam 
Bulgaria 
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Central African Republic 
Chad 
China
China, Hong Kong SAR 
China, Macao SAR 
Colombia
Comoros
Congo
Cote d’Ivoire
Democratic People’s Republic of Korea 
Democratic Republic of the Congo 
El Salvador Equatorial Guinea
Eritrea
Ethiopia
Fiji
Gabon
Gambia
Georgia
Ghana
Greenland
Guam
Guatemala
Guinea 
Guinea-Bissau 
Guyana
Haiti
Honduras
India 
Indonesia
Iraq
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People’s Democratic Republic 
Latvia
Lesotho
Liberia
Libya
Lithuania
Madagascar
Malawi


Mali
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia (Federated States of) 
Mongolia 
Montenegro
Morocco
Mozambique 
Myanmar
Namibia
Nauru
Nepal
New Caledonia
Nicaragua
Niger
Nigeria
Northern Mariana Islands 
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Portugal
Qatar
Republic of Korea
Republic of Moldova
Romania


Sao Tome and Principe
Senegal
Serbia
Sierra Leone
Singapore
Solomon Islands 
Somalia
South Africa
South Sudan
Sri Lanka
Sudan Suriname 
Swaziland
Syrian Arab Republic
Tajikistan
Tanzania (United Republic of)
Thailand
Timor-Leste
Togo
Tunisia
Turkmenistan
Tuvalu
Uganda
Ukraine
Uruguay
Uzbekistan
Vanuatu
Venezuela (Bolivarian Republic of)
Viet Nam
Yemen
Zambia
Zimbabwe 


3. Have you ever had close contact with persons known or suspected to have active TB disease?*
4. Have you been a resident or an employee in a high-risk congregate setting (e.g. prison/jail, long term care facility, homeless shelter, drug treatment center, residential facility for persons with HIV/AIDS)? (Yes)*
5. Have you been a volunteer or health care worker who served clients who are at increased risk for active TB disease?*
6. Have you ever been a member of any of the following groups that may have an increased incidence of latent M. tuberculosis infection or active TB disease: medically underserved, low- income, or abusing drugs or alcohol? (Yes)*
7. Have you ever had a documented positive TB skin test or history of active TB infection?*

If the answer is YES to questions 1-6, Walla Walla University requires TB testing as soon as possible but at least prior to the start of the quarter.

If the answer is NO to questions 1-6 and YES to question 7, Student Life will contact you with a few additional questions.

If the answers to all of the above questions are NO, no further testing or further action is required.

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