Bwergnwoienb

NSW Health
Tuberculosis (TB)
Assessment Tool
Occupational Assessment, Screening
and Vaccination Against Specified Infectious Diseases
Clear Form
Your Personal Information

Family Name Given Name(s)
Date of Birth Phone Number
Medicare Number [if eligible] Position on card [number next to your name] Expiry Date
Address (street number and name, suburb and postcode)
Email
Employer/Education Provider Stafflink/Student/Other ID
Course/Module of Study OR Place of Work
Signature Date completed
Please complete all questions in Parts A, B and C.
Part A: Symptoms requiring investigation to exclude active TB disease

Do you currently have any of the following symptoms that are not related to an existing diagnosis or
Yes No
condition that is being managed with a doctor?
1. Cough for more than 2 weeks?
2. Episodes of haemoptysis (coughing blood) in the past month?
3. Unexplained fevers, chills or night sweats in the past month?
4. Significant* unexpected weight loss over the past 3 months?

*loss of more than 5% of body weight
SHPN (HP NSW) 220521
1
Tuberculosis (TB)
Assessment Tool
Occupational Assessment, Screening and Vaccination Against Specified Infectious Diseases
Stafflink/Student/Other ID
Part B: Previous TB treatment or TB screening or increased susceptibility Yes No
Have you ever been treated for active TB disease or latent TB infection (LTBI)?
If Yes, please state the year and country where you were treated and provide documentation (if available)
Year Country
Have you ever had a positive TB skin test (TST) or blood test (IGRA or QuantiFERON TB Gold+)?
If Yes, please provide copies of TB test results.
Have you ever had a chest X-ray that was reported as abnormal?
Have you ever been referred to or reviewed in a TB service/chest clinic in Australia?
Do you have any medical conditions that affect your immune system?
e.g. cancer, HIV, auto- immune conditions such as rheumatoid arthritis, renal disease
Are you on any regular medications that suppress your immune system?
e.g. TNF alpha inhibitors, high dose prednisone
Please provide details here:
Part C: TB exposure risk history
The following questions explore possible exposure to TB at any time in your life (or since last TB Assessment)
1. Have you had direct contact with a person with infectious pulmonary TB and did not Yes No
complete contact screening?
2. In what country were you born?
If born overseas, when did you migrate to Australia?
3. Is your country of birth on the list of high-TB-incidence countries? Yes No

For the up-to-date list of high TB incidence countries, please go to
https://www.health.nsw.gov.au/Infectious/tuberculosis/Pages/high-incidence-countries.aspx
3a. If Yes, as part of your visa medical assessment, did you have a negative TB skin test
(TST) or blood test (IGRA or QuantiFERON TB Gold+)?
*If yes, please provide a copy of the result
4. Have you ever visited or lived in any country/ies with a high TB incidence?
If Yes, please list below the countries you have visited, the year of travel and duration of stay
Country visited Year Duration of stay Country visited Year of Duration of stay
of travel (please specify d/w/m) travel (please specify d/w/m)
2
Tuberculosis (TB)
Assessment Tool
Occupational Assessment, Screening and Vaccination Against Specified Infectious Diseases
Stafflink/Student/Other ID
Other relevant information to assist with determining TB risk

E.g. pre-migration TB screening - CXR reported as normal and negative IGRA on
Date
All workers and students need to submit this form to their NSW health agency or education provider.
Education providers must forward this form to the NSW Health agency for assessment.
The NSW Health agency will assess this form and determine whether TB screening or TB clinical review is required.
NSW TB Services contact details:
https://www.health.nsw.gov.au/Infectious/tuberculosis/Pages/accessing-your-local-TB-service.aspx
Privacy Notice: Personal information about students and employees collected by NSW Health is handled in accordance with the Health Records and Information
Privacy Act 2002. NSW Health is collecting your personal information to meet its obligations to protect the public and to provide a safe workplace as per the
current Occupational Assessment Screening and Vaccination Against Specified Infectious Diseases Policy Directive. All personal information will be securely
stored, and reasonable steps will be taken to keep it accurate, complete and up to date. Personal information recorded on this form will not be disclosed to NSW
Health officers or third parties unless the disclosure is authorised or required by or under law. If you choose not to provide your personal information, you will not
meet the condition of placement. For further information about how NSW Health protects your personal information, or to learn about your right to access your
own personal information, please see our website at www.health.nsw.gov.au
For Official Use of NSW Health Agency or NSW TB Service

Please refer to Appendix 3 - TB Assessment Decision Support Tool for guidance on documenting outcomes from this
TB Assessment:
TB Compliant
Advice sought from local TB service/chest clinic
TB Screening required – referred to GP or local TB service/chest clinic
TB Clinical Review required – referred to local TB service/chest clinic
Other
Name of assessor and role Contact Number
Health Agency/District/Network Date of assessment

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NSW Health

Your Personal Information

Date of Birth Phone Number

Address (street number and name, suburb and postcode)

Employer/Education Provider Stafflink/Student/Other ID

Course/Module of Study OR Place of Work

Signature Date completed

Please complete all questions in Parts A, B and C.

Part A: Symptoms requiring investigation to exclude active TB disease

1. Cough for more than 2 weeks?

2. Episodes of haemoptysis (coughing blood) in the past month?

3. Unexplained fevers, chills or night sweats in the past month?

4. Significant* unexpected weight loss over the past 3 months?

SHPN (HP NSW) 220521

Family Name Given Name(s)

Part B: Previous TB treatment or TB screening or increased susceptibility Yes No

Have you ever been referred to or reviewed in a TB service/chest clinic in Australia?

Part C: TB exposure risk history

2. In what country were you born?

If born overseas, when did you migrate to Australia?

3. Is your country of birth on the list of high-TB-incidence countries? Yes No

Family Name Given Name(s)

Other relevant information to assist with determining TB risk

For Official Use of NSW Health Agency or NSW TB Service

Name of assessor and role Contact Number

Health Agency/District/Network Date of assessment

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3. Is your country of birth on the list of high-TB-incidence countries? Yes No