Delaware Department or Education

CONFIDENTIAL TUBERCULOSIS (TB) HEALTH QUESTIONNAIRE FOR VOLUNTEERS IN PUBLIC SCHOOLS

All school students, employees. and volunteers are required to be screened for tuberculosis (TB).  The purpose of this requirement is to safeguard school-aged children from exposure to TB in the school setting. This questionnaire is designed to identify volunteers who MAY have been exposed to TB and thus need further testing. A school designee will collect and monitor the Health Questionnaire, which will be stored in the School Nurse's office in a confidential manner. The questionnaire must be completed every five years. The volunteer may prefer to provide evidence of TB testing in lieu of completing the questionnaire.

Please read the following questions and answer the prompt below:

1. In the past five years, have you lived or been in close contact with anyone who had active, infectious TB disease?
2. Do you currently have any of the following symptoms which are unexplained and which have lasted at least three weeks?
   1. Cough
   2. Fever
   3. Weight loss
   4. Night sweats
3. Are you aware of being immunosuppressed (a suppression of the immune system and its ability to fight infection, increasing your likelihood of developing active TB, which may be caused by a particular illness or medical treatment such as certain types of cancer. silicosis, HIV/AIDS. organ transplant recipient, use of TNF-alpha antagonists ["biologies"], or long-term, high dose steroids)?
4. In the past five years, have you ever used illegal intravenous drugs?
5. In the past five years. have you been incarcerated?
6. In the past five years, have you been homeless which resulted in living in a shelter or with others outside of your family. who were homeless?
7. For the next two questions, have you traveled to any area(s) where TB is common? Per the Delaware Division of Public Health, this includes travel or residency in a country with an elevated TB rate for at least 1 month. This includes any country other than the United States, Canada, Australia, New Zealand, or a country in western or northern Europe
   
   1. In the past five years, have you stayed/lived in one of these countries for 1 month or longer?
   2. In the past five years, have you lived or been in close contact with someone who stayed/lived in one of these countries for 1 month or longer?

 

If you checked YES, you are required (within 2 weeks) to provide verification from a licensed health care provider or the Division of Public Health that there is no communicable threat.

If you checked yes, you are required to provide documentation related to current disease status prior to your assignment or continued assignment as a volunteer. If you have provided documentation of completing treatment for active or latent infection, no further documentation is required.

These requirements are for the safety of our school and for your personal health. Screening for tuberculosis is recommended by health professionals for any individual who is at risk. Routine screening, using a Mantoux tuberculin skin test or a TB blood test, such as the Quantiferon Gold TB Test, can detect if a person has been exposed to tuberculosis. Early identification of infection and completion of a course of antibiotic treatment significantly reduces the chance of developing active TB disease over the lifetime of infected individuals.

If you have any questions about your risk of infection, please speak with your healthcare provider or plan to discuss it at your next examination.

For additional information, you can contact the Delaware Division of Public Health TB Elimination Program at 302-744-1050.

Developed and revised in collaboration with the Delaware Division of Public Health: 2/2005, 7/2010, 7/2013, 5/2015, 4/2018; 12/2019

Regulation 805 can be accessed at http://www.state.de.us/research/AdminCode/title14/800.

To maintain confidentiality of medical information, the volunteer should not provide an individual answer to each question. The volunteer’s response of “yes” indicates that at least one of the seven questions is correct, which means a possible exposure. The volunteer should not indicate which one. The volunteer may prefer to provide evidence of TB testing in lieu of completing the questionnaire.

CDC describes “close contact” as prolonged, frequent, or intense contact with a person with TB, while he/she was in infectious.