The TB Document may be needed to enter school. Please fill out this form for our staff to review to write you a letter. Allow us up to the next business day to complete this.

Your Name

First Name

Last Name

Relation to patient

Patient Name

First Name

Last Name

Check for TB Symptoms - Cough for 3 weeks or more PLUS at least one of the following: coughing blood, fever, night sweats, unexplained weight loss, unusual weakness, or fatigue.

Was this person born in a country with elevated TB rates?

Includes countries other than the United States, Canada, Australia, New Zealand, or Western and Northern European Countries)

Has this person traveled to (or lived in) a country with an elevated TB rate for four weeks or longer?

At any time has this person been in contact with someone with infectious TB disease?

Does the individual have a health problem that affects the immune system, or is medial treatment planned that may affect the immune system?

Includes HIV/AIDS, organ transplant recipient, treatment with TNF-alpha antagonist, or steroid medication for a month or longer

For persons under the age 16 only: Is someone in the child's household from a country with an elevated TB rate?

Child's School