Tuberculosis Screening Questionnaire

TUBERCULOSIS (TB) SCREENING QUESTIONNAIRE

Upon matriculation at Missouri Western State University, all students will complete the TB screening questionnaire in compliance with Missouri State Law. Upon hiring at Missouri Western State University, all faculty and staff will complete the TB screening questionnaire to aid in prevention and control of Tuberculosis.

Tuberculosis, also known as TB, is a bacterial infection that attacks the lungs and, sometimes, other parts of the body. It is spread when someone infected with the disease coughs or sneezes and the bacteria is inhaled by someone nearby. For additional information on TB: www.cdc.gov/tb/publications/factsheets/default.htm

G Number:

If you answered YES to any of the above questions, you are required to provide documentation of a tuberculosis test from a certified U.S. Healthcare Provider, dated no sooner than 6 months prior to the student/faculty/staff MWSU start date.

It is highly recommended to undergo a TB blood test instead of a TB skin test, if you were born in a country on the list or have received the BCG vaccination, due to the risk of a possible false positive.
If you have received prior treatment for active TB disease from a certified U. S. Healthcare Provider, you will need to provide proper documentation of such treatment to the Esry Student Health Center.

All tests can be obtained at the Esry Student Health Center (for students), or by a U.S. certified health care provider. All medical expenses will be the individual’s financial responsibility.

To the best of my knowledge, the information provided above is true and complete. I acknowledge that non-compliance will result in students not being eligible to enroll for a subsequent semester; faculty / staff members may not work on campus until screening is complete, per Missouri Western State University policy and Missouri law.