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About Drury
Academic Calendar
Additional Departments
Alumni & Giving
Athletics
Bookstore
Directory
Diversity, Equity and Inclusion
Facility Hours
Giving to Drury
Library
Military
Safety & Security
Student Services & Resources
Working at Drury

TB Screening Form

Drury University > Forms > TB Screening Form

Name *

First

Last

Drury ID Number *

Position *

Department *

Email Address *

Phone Number *

If the answer is YES to any question, Drury University requires that a healthcare provider complete a TB risk assessment as a condition of employment.

If the answer to all of the following questions is NO, no further testing or further action is required.

Have you ever had a positive TB skin test? *

Yes
No

Have you ever had close contact with persons or suspected to have active TB disease? *

Yes
No

Were you born in one of the countries listed below that have a high incidence of active TB disease? *

Yes
No

Source: World Health Organization Global Health Observatory, Tuberculosis Incidence 2010. Countries with incidence rates of > 20 cases per 100,000 population.

Have you had frequent or prolonged visits* to one or more of the countries listed above with a high prevalence of TB disease? *

Yes
No

Please list the countries where you had prolonged visits

Have you ever been vaccinated with BCG? *

Yes
No

Have you been a resident and/or employee of high-risk congregate settings (e.g., correctional facilities, long-term care facilities, and homeless shelters)? *

Yes
No

Have you been a volunteer or health-care worker who served clients who are at increased risk for active TB disease? *

Yes
No

Have you ever been a member of any of the following groups that may have increased incidence of latent <em>M. tuberculosis</em> infection or active TB disease - medically underserved, low-income, or abusing drugs or alcohol? *

Yes
No

CONTACT

Frequently Used Phone Numbers
Email: drury@drury.edu

ADDRESS

900 North Benton Avenue
Springfield, MO 65802

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