First Name:	Middle Initial:
Last Name:
Positive TB Skin Test (PPD) Date:
Last Chest X-Ray Date:

Please indicate if you have had any of the following problems for three to four weeks or longer:
Chronic Cough (greater than three weeks):	Yes    No
Production of Sputum:	Yes    No
Blood Streaked Sputum:	Yes    No
Unexplained Weight Loss:	Yes    No
Fever:	Yes    No
Fatigue/Tiredness:	Yes    No
Night Sweats:	Yes    No
Shortness of Breath:	Yes    No

	The information I have given is true and accurate AND THERE IS NO EVIDENCE OF PULMONARY TUBERCULOSIS OR CONTAGIUM. Applicants with negative TB skin test results or recent chest x-rays (less than 1 year) do not need the physician signed TB questionnaire. Please download PDF version of this form and print for Physician's signature if needed. Date:

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