**Appendix B. Tuberculosis (TB) risk assessment worksheet**

This model worksheet should be considered for use in performing TB risk
assessments for health-care facilities and nontraditional facility-based
settings. Facilities with more than one type of setting will need to
apply this table to each setting.

  -----------------------------------------------------------------------
  **Scoring √ or Y = Yes X or N = No NA = Not Applicable**

  -----------------------------------------------------------------------

**1. Incidence of TB**

+---------------------------------------------------+------------------+
| What is the incidence of TB in your community     | Community        |
| (county or region served by the health-care       | ra               |
| setting), and how does it compare with the state  | te\_\_\_\_\_\_\_ |
| and national average? What is the incidence of TB |                  |
| in your facility and specific settings and how do | State rate       |
| those rates compare? (Incidence is the number of  | \_\_\_\_         |
| TB cases in your community the previous year. A   | \_\_\_\_\_\_\_\_ |
| rate of TB cases per 100,000 persons should be    |                  |
| obtained for comparison.)\* This information can  | National rate    |
| be obtained from the state or local health        | \_               |
| department.                                       | \_\_\_\_\_\_\_\_ |
|                                                   |                  |
|                                                   | Facility rate    |
|                                                   | \_\_             |
|                                                   | \_\_\_\_\_\_\_\_ |
|                                                   |                  |
|                                                   | Department 1     |
|                                                   | rate             |
|                                                   | \_\_\_\_\_\_\_   |
|                                                   |                  |
|                                                   | Department 2     |
|                                                   | rate             |
|                                                   | \_\_\_\_\_\_\_   |
|                                                   |                  |
|                                                   | Department 3     |
|                                                   | rate             |
|                                                   | \_\_\_\_\_\_\_   |
+---------------------------------------------------+------------------+
| Are patients with suspected or confirmed TB       | Yes No           |
| disease encountered in your setting (inpatient    |                  |
| and outpatient)?                                  |                  |
+---------------------------------------------------+------------------+
| If yes, how many patients with suspected and      | Year No.         |
| confirmed TB disease are treated in your          | patients         |
| health-care setting in 1 year (inpatient and      |                  |
| outpatient)? Review laboratory data,              | Suspected        |
| infection-control records, and databases          | Confirmed        |
| containing discharge diagnoses.                   |                  |
|                                                   | 1 year ago       |
|                                                   | \_\_\_\_\_       |
|                                                   | \_\_\_\_\_       |
|                                                   |                  |
|                                                   | 2 years ago      |
|                                                   | \_\_\_\_\_       |
|                                                   | \_\_\_\_\_       |
|                                                   |                  |
|                                                   | 5 years ago      |
|                                                   | \_\_\_\_\_       |
|                                                   | \_\_\_\_\_       |
+---------------------------------------------------+------------------+
| If no, does your health-care setting have a plan  | Yes No           |
| for the triage of patients with suspected or      |                  |
| confirmed TB disease?                             |                  |
+---------------------------------------------------+------------------+
| Currently, does your health-care setting have a   | Yes No           |
| cluster of persons with confirmed TB disease that |                  |
| might be a result of ongoing transmission of      |                  |
| *Mycobacterium tuberculosis* within your setting  |                  |
| (inpatient and outpatient)?                       |                  |
+---------------------------------------------------+------------------+

**2. Risk Classification**

+----------------------------------------------------+-----------------+
| **Inpatient settings**                             |                 |
+----------------------------------------------------+-----------------+
| How many inpatient beds are in your inpatient      |                 |
| setting?                                           |                 |
+----------------------------------------------------+-----------------+
| How many patients with TB disease are encountered  | Previous year   |
| in the inpatient setting in 1 year? Review         | \_\_\_\_\_\_    |
| laboratory data, infection-control records, and    |                 |
| databases containing discharge diagnoses.          | 5 years ago     |
|                                                    | \_\_\_\_\_\_    |
+----------------------------------------------------+-----------------+
| Depending on the number of beds and TB patients    | ο Low risk      |
| encountered in 1 year, what is the risk            |                 |
| classification for your inpatient setting? (See    | ο Medium risk   |
| Appendix C.)                                       |                 |
|                                                    | ο Potential     |
|                                                    | ongoing         |
|                                                    | transmission    |
+----------------------------------------------------+-----------------+
| Does your health-care setting have a plan for the  | Yes No          |
| triage of patients with suspected or confirmed TB  |                 |
| disease?                                           |                 |
+----------------------------------------------------+-----------------+
| **Outpatient settings**                            |                 |
+----------------------------------------------------+-----------------+
| How many TB patients are evaluated at your         | Previous year   |
| outpatient setting in 1 year? Review laboratory    | \_\_\_\_\_\_    |
| data, infection-control records, and databases     |                 |
| containing discharge diagnoses.                    | 5 years ago     |
|                                                    | \_\_\_\_\_\_    |
+----------------------------------------------------+-----------------+
| Is your health-care setting a TB clinic?           | Yes No          |
|                                                    |                 |
| (If yes, a classification of at least medium risk  |                 |
| is recommended.)                                   |                 |
+----------------------------------------------------+-----------------+
| Does evidence exist that a high incidence of TB    | Yes No          |
| disease has been observed in the community that    |                 |
| the health-care setting serves?                    |                 |
+----------------------------------------------------+-----------------+
| Does evidence exist of person-to-person            | Yes No          |
| transmission of *M. tuberculosis* in the           |                 |
| health-care setting? (Use information from case    |                 |
| reports. Determine if any tuberculin skin test     |                 |
| \[TST\] or blood assay for *M. tuberculosis*       |                 |
| \[BAMT\] conversions have occurred among           |                 |
| health-care workers \[HCWs\]).                     |                 |
+----------------------------------------------------+-----------------+
| Does evidence exist that ongoing or unresolved     | Yes No          |
| health-care--associated transmission has occurred  |                 |
| in the health-care setting (based on case          |                 |
| reports)?                                          |                 |
+----------------------------------------------------+-----------------+
| Is there a high incidence of immunocompromised     | Yes No          |
| patients or HCWs in the health-care setting?       |                 |
+----------------------------------------------------+-----------------+
| Have patients with drug-resistant TB disease been  | Yes No          |
| encountered in your health-care setting within the |                 |
| previous 5 years?                                  | Year            |
|                                                    | \               |
|                                                    | _\_\_\_\_\_\_\_ |
+----------------------------------------------------+-----------------+
| When was the first time a risk classification was  | \_\_\_          |
| done for your health-care setting?                 | \_\_\_\_\_\_\_\ |
|                                                    | _\_\_\_\_\_\_\_ |
+----------------------------------------------------+-----------------+
| Considering the items above, would your            | Yes No          |
| health-care setting need a higher risk             |                 |
| classification?                                    |                 |
+----------------------------------------------------+-----------------+
| Depending on the number of TB patients evaluated   | ο Low risk      |
| in 1 year, what is the risk classification for     |                 |
| your outpatient setting? (See Appendix C)          | ο Medium risk   |
|                                                    |                 |
|                                                    | ο Potential     |
|                                                    | ongoing         |
|                                                    | transmission    |
+----------------------------------------------------+-----------------+
| Does your health-care setting have a plan for the  | Yes No          |
| triage of patients with suspected or confirmed TB  |                 |
| disease?                                           |                 |
+----------------------------------------------------+-----------------+
| **Nontraditional facility-based settings**         |                 |
+----------------------------------------------------+-----------------+
| How many TB patients are encountered at your       | Previous year   |
| setting in 1 year?                                 | \_\_\_\_\_\_    |
|                                                    |                 |
|                                                    | 5 years ago     |
|                                                    | \_\_\_\_\_\_    |
+----------------------------------------------------+-----------------+
| Does evidence exist that a high incidence of TB    | Yes No          |
| disease has been observed in the community that    |                 |
| the setting serves?                                |                 |
+----------------------------------------------------+-----------------+
| Does evidence exist of person-to-person            | Yes No          |
| transmission of *M. tuberculosis* in the setting?  |                 |
+----------------------------------------------------+-----------------+
| Have any recent TST or BAMT conversions occurred   | Yes No          |
| among staff or clients?                            |                 |
+----------------------------------------------------+-----------------+
| Is there a high incidence of immunocompromised     | Yes No          |
| patients or HCWs in the setting?                   |                 |
+----------------------------------------------------+-----------------+
| Have patients with drug-resistant TB disease been  | Yes No          |
| encountered in your health-care setting within the |                 |
| previous 5 years?                                  | Year            |
|                                                    | \               |
|                                                    | _\_\_\_\_\_\_\_ |
+----------------------------------------------------+-----------------+
| When was the first time a risk classification was  |                 |
| done for your setting?                             |                 |
+----------------------------------------------------+-----------------+
| Considering the items above, would your setting    | Yes No          |
| require a higher risk classification?              |                 |
+----------------------------------------------------+-----------------+
| Does your setting have a plan for the triage of    | Yes No          |
| patients with suspected or confirmed TB disease?   |                 |
+----------------------------------------------------+-----------------+
| Depending on the number of patients with TB        | ο Low risk      |
| disease who are encountered in a nontraditional    |                 |
| setting in 1 year, what is the risk classification | ο Medium risk   |
| for your setting? (See Appendix C)                 |                 |
|                                                    | ο Potential     |
|                                                    | ongoing         |
|                                                    | transmission    |
+----------------------------------------------------+-----------------+

**3. Screening of HCWs for *M. tuberculosis* Infection**

+---------------------------------------+---+------------+---------------+
| Does the health-care setting have a   | Y |            |               |
| TB screening program for HCWs?        | e |            |               |
|                                       | s |            |               |
|                                       | N |            |               |
|                                       | o |            |               |
+---------------------------------------+---+------------+---------------+
| If yes, which HCWs are included in    | ο |            |               |
| the TB screening program? (Check all  | J |            |               |
| that apply.)                          | a |            |               |
|                                       | n |            |               |
| > ο Physicians                        | i |            |               |
| >                                     | t |            |               |
| > ο Mid-level practitioners (nurse    | o |            |               |
| > practitioners \[NP\] and            | r |            |               |
| > physician's assistants \[PA\])      | i |            |               |
| >                                     | a |            |               |
| > ο Nurses                            | l |            |               |
| >                                     | s |            |               |
| > ο Administrators                    | t |            |               |
| >                                     | a |            |               |
| > ο Laboratory workers                | f |            |               |
| >                                     | f |            |               |
| > ο Respiratory therapists            |   |            |               |
| >                                     | ο |            |               |
| > ο Physical therapists               | M |            |               |
| >                                     | a |            |               |
| > ο Contract staff                    | i |            |               |
|                                       | n |            |               |
| ο Construction or renovation workers  | t |            |               |
|                                       | e |            |               |
| ο Service workers                     | n |            |               |
|                                       | a |            |               |
|                                       | n |            |               |
|                                       | c |            |               |
|                                       | e |            |               |
|                                       | o |            |               |
|                                       | r |            |               |
|                                       | e |            |               |
|                                       | n |            |               |
|                                       | g |            |               |
|                                       | i |            |               |
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|                                       | e |            |               |
|                                       | e |            |               |
|                                       | r |            |               |
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|                                       | n |            |               |
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|                                       | t |            |               |
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|                                       | f |            |               |
|                                       |   |            |               |
|                                       | ο |            |               |
|                                       | T |            |               |
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|                                       | \ |            |               |
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|                                       | _ |            |               |
|                                       | \ |            |               |
|                                       | _ |            |               |
|                                       | \ |            |               |
|                                       | _ |            |               |
|                                       | \ |            |               |
|                                       | _ |            |               |
|                                       | \ |            |               |
|                                       | _ |            |               |
|                                       | \ |            |               |
|                                       | _ |            |               |
|                                       | \ |            |               |
|                                       | _ |            |               |
|                                       | \ |            |               |
|                                       | _ |            |               |
|                                       | \ |            |               |
|                                       | _ |            |               |
|                                       | \ |            |               |
|                                       | _ |            |               |
|                                       | \ |            |               |
|                                       | _ |            |               |
|                                       | \ |            |               |
|                                       | _ |            |               |
|                                       | \ |            |               |
|                                       | _ |            |               |
|                                       | \ |            |               |
|                                       | _ |            |               |
|                                       | \ |            |               |
|                                       | _ |            |               |
|                                       | \ |            |               |
|                                       | _ |            |               |
+---------------------------------------+---+------------+---------------+
| Is baseline skin testing performed    |   |            | Yes No        |
| with two-step TST for HCWs?           |   |            |               |
+---------------------------------------+---+------------+---------------+
| Is baseline testing performed with    |   |            | Yes No        |
| QFT or other BAMT for HCWs?           |   |            |               |
+---------------------------------------+---+------------+---------------+
| How frequently are HCWs tested for    |   |            |               |
| *M. tuberculosis* infection?          |   |            |               |
+---------------------------------------+---+------------+---------------+
| Are the *M. tuberculosis* infection   |   |            | Yes No        |
| test records maintained for HCWs?     |   |            |               |
+---------------------------------------+---+------------+---------------+
| Where are the *M. tuberculosis*       |   |            |               |
| infection test records for HCWs       |   |            |               |
| maintained? Who maintains the         |   |            |               |
| records?                              |   |            |               |
+---------------------------------------+---+------------+---------------+
| If the setting has a serial TB        |   |            |               |
| screening program for HCWs to test    |   |            |               |
| for *M. tuberculosis* infection, what |   |            |               |
| are the conversion rates for the      |   |            |               |
| previous years? **^†^**               |   |            |               |
|                                       |   |            |               |
| 1 year ago                            |   |            |               |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 4  |   |            |               |
| years ago                             |   |            |               |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_    |   |            |               |
|                                       |   |            |               |
| 2 years ago                           |   |            |               |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 5  |   |            |               |
| years ago                             |   |            |               |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_    |   |            |               |
|                                       |   |            |               |
| 3 years ago                           |   |            |               |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_    |   |            |               |
+---------------------------------------+---+------------+---------------+
| Has the test conversion rate for *M.  |   | ο          |               |
| tuberculosis* infection been          |   | Increasing |               |
| increasing or decreasing, or has it   |   |            |               |
| remained the same over the previous 5 |   | ο          |               |
| years? (check one)                    |   | Decreasing |               |
|                                       |   |            |               |
|                                       |   | ο No       |               |
|                                       |   | change     |               |
+---------------------------------------+---+------------+---------------+
| Do any areas of the health-care       |   | Yes No     |               |
| setting (e.g., waiting rooms or       |   |            |               |
| clinics) or any group of HCWs (e.g.,  |   | If yes,    |               |
| lab workers, emergency department     |   | list       |               |
| staff, respiratory therapists, and    |   | \_\_\_\_\_ |               |
| HCWs who attend bronchoscopies) have  |   | \_\_\_\_\_ |               |
| a test conversion rate for *M.        |   | \_\_\_\_\_ |               |
| tuberculosis* infection that exceeds  |   | \_\_\_\_\_ |               |
| the health-care setting's annual      |   | \_\_\_\_\_ |               |
| average?                              |   |            |               |
|                                       |   | \_\_\_     |               |
|                                       |   | \_\_\_\_\_ |               |
|                                       |   | \_\_\_\_\_ |               |
|                                       |   | \_\_\_\_\_ |               |
|                                       |   | \_\_\_\_\_ |               |
|                                       |   | \_\_\_\_\_ |               |
|                                       |   | \_\_\_\_\_ |               |
|                                       |   |            |               |
|                                       |   | \_\_\_     |               |
|                                       |   | \_\_\_\_\_ |               |
|                                       |   | \_\_\_\_\_ |               |
|                                       |   | \_\_\_\_\_ |               |
|                                       |   | \_\_\_\_\_ |               |
|                                       |   | \_\_\_\_\_ |               |
|                                       |   | \_\_\_\_\_ |               |
+---------------------------------------+---+------------+---------------+
| For HCWs who have positive test       |   | Yes No Not |               |
| results for *M. tuberculosis*         |   | applicable |               |
| infection and who leave employment at |   |            |               |
| the health setting, are efforts made  |   |            |               |
| to communicate test results and       |   |            |               |
| recommend follow-up of latent TB      |   |            |               |
| infection (LTBI) treatment with the   |   |            |               |
| local health department or their      |   |            |               |
| primary physician?                    |   |            |               |
+---------------------------------------+---+------------+---------------+

**4. TB Infection-Control Program**

+-----------------------------------------+------------+---------------+
| Does the health-care setting have a     |            | Yes No        |
| written TB infection-control plan?      |            |               |
+-----------------------------------------+------------+---------------+
| Who is responsible for the              |            |               |
| infection-control program?              |            |               |
+-----------------------------------------+------------+---------------+
| When was the TB infection-control plan  |            |               |
| first written?                          |            |               |
+-----------------------------------------+------------+---------------+
| When was the TB infection-control plan  |            |               |
| last reviewed or updated?               |            |               |
+-----------------------------------------+------------+---------------+
| Does the written infection-control plan |            | Yes No        |
| need to be updated based on the timing  |            |               |
| of the previous update (i.e., \>1 year, |            |               |
| changing TB epidemiology of the         |            |               |
| community or setting, the occurrence of |            |               |
| a TB outbreak, change in state or local |            |               |
| TB policy, or other factors related to  |            |               |
| a change in risk for transmission of    |            |               |
| *M. tuberculosis*)?                     |            |               |
+-----------------------------------------+------------+---------------+
| Does the health-care setting have an    |            | Yes No        |
| infection-control committee (or another |            |               |
| committee with infection control        |            |               |
| responsibilities)?                      |            |               |
+-----------------------------------------+------------+---------------+
| If yes, which groups are represented on | ο          |               |
| the infection-control committee? (Check | Laboratory |               |
| all that apply.)                        | personnel  |               |
|                                         |            |               |
| ο Physicians                            | ο Health   |               |
|                                         | and safety |               |
| ο Nurses                                | staff      |               |
|                                         |            |               |
| ο Epidemiologists                       | ο          |               |
|                                         | Adm        |               |
| ο Engineers                             | inistrator |               |
|                                         |            |               |
| ο Pharmacists                           | ο Risk     |               |
|                                         | assessment |               |
|                                         |            |               |
|                                         | ο Quality  |               |
|                                         | control    |               |
|                                         | (QC)       |               |
|                                         |            |               |
|                                         | ο Others   |               |
|                                         | (specif    |               |
|                                         | y)\_\_\_\_ |               |
|                                         | \_\_\_\_\_ |               |
+-----------------------------------------+------------+---------------+
| If no, what committee is responsible    |            |               |
| for infection control in the setting?   |            |               |
+-----------------------------------------+------------+---------------+

**5. Implementation of TB Infection-Control Plan Based on Review by
Infection-Control Committee**

+-----------------------------------------+----------------------------+
| Has a person been designated to be      | Yes No                     |
| responsible for implementing an         |                            |
| infection-control plan in your          |                            |
| health-care setting? If yes, list the   |                            |
| name:                                   |                            |
| \_\_\_\_\_\                             |                            |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |                            |
+-----------------------------------------+----------------------------+
| Based on a review of the medical        |                            |
| records, what is the average number of  |                            |
| days for the following:                 |                            |
|                                         |                            |
| -   Presentation of patient until       |                            |
|     collection of specimen \_\_\_\_\_   |                            |
|                                         |                            |
| -   Specimen collection until receipt   |                            |
|     by laboratory \_\_\_\_\_            |                            |
|                                         |                            |
| -   Receipt of specimen by laboratory   |                            |
|     until smear results are provided to |                            |
|     health-care provider \_\_\_\_\_     |                            |
|                                         |                            |
| -   Diagnosis until initiation of       |                            |
|     standard antituberculosis treatment |                            |
|     \_\_\_\_\_                          |                            |
|                                         |                            |
| -   Receipt of specimen by laboratory   |                            |
|     until culture results are provided  |                            |
|     to health-care provider \_\_\_\_\_  |                            |
|                                         |                            |
| -   Receipt of specimen by laboratory   |                            |
|     until drug-susceptibility results   |                            |
|     are provided to                     |                            |
|                                         |                            |
| health-care provider \_\_\_\_\_         |                            |
|                                         |                            |
| -   Receipt of drug-susceptibility      |                            |
|     results until adjustment of         |                            |
|     antituberculosis treatment,         |                            |
|                                         |                            |
| if indicated \_\_\_\_\_                 |                            |
|                                         |                            |
| -   Admission of patient to hospital    |                            |
|     until placement in airborne         |                            |
|     infection isolation (AII)           |                            |
|     \_\_\_\_\_                          |                            |
+-----------------------------------------+----------------------------+
| Through what means (e.g., review of TST |                            |
| or BAMT conversion rates, patient       |                            |
| medical records, and time analysis) are |                            |
| lapses in infection control recognized? |                            |
+-----------------------------------------+----------------------------+
| What mechanisms are in place to correct |                            |
| lapses in infection control?            |                            |
+-----------------------------------------+----------------------------+
| Based on measurement in routine QC      | Yes No                     |
| exercises, is the infection-control     |                            |
| plan being properly implemented?        |                            |
+-----------------------------------------+----------------------------+
| Is ongoing training and education       | Yes No                     |
| regarding TB infection-control          |                            |
| practices provided for HCWs?            |                            |
+-----------------------------------------+----------------------------+

**6. Laboratory Processing of TB-Related Specimens, Tests, and Results
Based on Laboratory Review**

+-------------------------------------------------+---------+---------+
| Which of the following tests are either         | I       | Sent    |
| conducted in-house at your health-care          | n-house | out     |
| setting's laboratory or sent out to a reference |         |         |
| laboratory?                                     |         |         |
+-------------------------------------------------+---------+---------+
| Acid-fast bacilli (AFB) smears                  |         |         |
+-------------------------------------------------+---------+---------+
| Culture using liquid media (e.g., Bactec and    |         |         |
| MB-BacT)                                        |         |         |
+-------------------------------------------------+---------+---------+
| Culture using solid media                       |         |         |
+-------------------------------------------------+---------+---------+
| Drug-susceptibility testing                     |         |         |
+-------------------------------------------------+---------+---------+
| Nucleic acid amplification (NAA) testing        |         |         |
+-------------------------------------------------+---------+---------+
| What is the usual transport time for specimens  |         |         |
| to reach the laboratory for the following       |         |         |
| tests?                                          |         |         |
|                                                 |         |         |
| > AFB smears \_\_\_\_\_\_\_\_\_\_\_             |         |         |
| >                                               |         |         |
| > Culture using liquid media (e.g., Bactec,     |         |         |
| > MB-BacT) \_\_\_\_\_\_\_\_\_\_\_               |         |         |
| >                                               |         |         |
| > Culture using solid media                     |         |         |
| > \_\_\_\_\_\_\_\_\_\_\_                        |         |         |
| >                                               |         |         |
| > Drug-susceptibility testing                   |         |         |
| > \_\_\_\_\_\_\_\_\_\_\_                        |         |         |
| >                                               |         |         |
| > Other (specify) \_\_\_\_\_\_\_\_\_\_\_        |         |         |
| >                                               |         |         |
| > NAA testing \_\_\_\_\_\_\_\_\_\_\_            |         |         |
+-------------------------------------------------+---------+---------+
| Does the laboratory at your health-care setting | Yes No  |         |
| or the reference laboratory used by your        |         |         |
| health-care setting report AFB smear results    | \_      |         |
| for all patients within 24 hours of receipt of  | \_\_\_\ |         |
| specimen? What is the procedure for weekends?   | _\_\_\_ |         |
|                                                 | \_\_\_\ |         |
|                                                 | _\_\_\_ |         |
|                                                 | \_\_\_\ |         |
|                                                 | _\_\_\_ |         |
|                                                 |         |         |
|                                                 | \_      |         |
|                                                 | \_\_\_\ |         |
|                                                 | _\_\_\_ |         |
|                                                 | \_\_\_\ |         |
|                                                 | _\_\_\_ |         |
|                                                 | \_\_\_\ |         |
|                                                 | _\_\_\_ |         |
+-------------------------------------------------+---------+---------+

**7. Environmental Controls**

+-----------------------------------+----------+----------+----------+
| Which environmental controls are  |          |          |          |
| in place in your health-care      |          |          |          |
| setting? (Check all that apply    |          |          |          |
| and describe)                     |          |          |          |
|                                   |          |          |          |
| [Environmental                    |          |          |          |
| control]{.underline}              |          |          |          |
| [Description]{.underline}         |          |          |          |
|                                   |          |          |          |
| ο AII rooms                       |          |          |          |
| \_\_\_\_\                         |          |          |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |          |          |
|                                   |          |          |          |
| ο Local exhaust ventilation       |          |          |          |
| (enclosing devices and exterior   |          |          |          |
| devices)                          |          |          |          |
| \_\_\_\_\                         |          |          |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |          |          |
|                                   |          |          |          |
| ο General ventilation (e.g.,      |          |          |          |
| single-pass system, recirculation |          |          |          |
| system.)                          |          |          |          |
| \_\_\_\_\                         |          |          |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |          |          |
|                                   |          |          |          |
| ο Air-cleaning methods (e.g.,     |          |          |          |
| high-efficiency particulate air   |          |          |          |
| \[HEPA\] filtration and           |          |          |          |
| ultraviolet germicidal            |          |          |          |
| irradiation \[UVGI\])             |          |          |          |
| \_\_\_\_\_\_\_\_\_\               |          |          |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |          |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |          |          |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |          |          |
+-----------------------------------+----------+----------+----------+
| What are the actual air changes   |          |          |          |
| per hour (ACH) and design for     |          |          |          |
| various rooms in the setting?     |          |          |          |
|                                   |          |          |          |
| [Room]{.underline}                |          |          |          |
| [ACH]{.underline}                 |          |          |          |
| [Design]{.underline}              |          |          |          |
|                                   |          |          |          |
| \_\_\                             |          |          |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |          |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |          |          |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |          |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |          |          |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |          |          |
|                                   |          |          |          |
| \_\_\                             |          |          |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |          |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |          |          |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |          |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |          |          |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |          |          |
|                                   |          |          |          |
| \_\_\                             |          |          |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |          |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |          |          |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |          |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |          |          |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |          |          |
|                                   |          |          |          |
| \_\_\                             |          |          |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |          |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |          |          |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |          |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |          |          |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |          |          |
|                                   |          |          |          |
| \_\_\                             |          |          |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |          |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |          |          |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |          |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |          |          |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |          |          |
+-----------------------------------+----------+----------+----------+
| Which of the following local      |          |          |          |
| exterior or enclosing devices     |          |          |          |
| such as exhaust ventilation       |          |          |          |
| devices are used in your          |          |          |          |
| health-care setting? (Check all   |          |          |          |
| that apply)                       |          |          |          |
|                                   |          |          |          |
| ο Laboratory hoods                |          |          |          |
|                                   |          |          |          |
| ο Booths for sputum induction     |          |          |          |
|                                   |          |          |          |
| ο Tents or hoods for enclosing    |          |          |          |
| patient or procedure              |          |          |          |
+-----------------------------------+----------+----------+----------+
| What general ventilation systems  |          |          |          |
| are used in your health-care      |          |          |          |
| setting? (Check all that apply)   |          |          |          |
|                                   |          |          |          |
| ο Single-pass system              |          |          |          |
|                                   |          |          |          |
| ο Variable air volume (VAV)       |          |          |          |
|                                   |          |          |          |
| ο Constant air volume (CAV)       |          |          |          |
|                                   |          |          |          |
| ο Recirculation system            |          |          |          |
|                                   |          |          |          |
| ο                                 |          |          |          |
| Other\_\_\_\                      |          |          |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |          |          |
+-----------------------------------+----------+----------+----------+
| What air-cleaning methods are     |          |          |          |
| used in your health-care setting? |          |          |          |
| (Check all that apply)            |          |          |          |
|                                   |          |          |          |
| [HEPA filtration]{.underline}     |          |          |          |
|                                   |          |          |          |
| > ο Fixed room-air recirculation  |          |          |          |
| > systems                         |          |          |          |
| >                                 |          |          |          |
| > ο Portable room-air             |          |          |          |
| > recirculation systems           |          |          |          |
|                                   |          |          |          |
| [UVGI]{.underline}                |          |          |          |
|                                   |          |          |          |
| > ο Duct irradiation              |          |          |          |
| >                                 |          |          |          |
| > ο Upper-air irradiation         |          |          |          |
| >                                 |          |          |          |
| > ο Portable room-air cleaners    |          |          |          |
+-----------------------------------+----------+----------+----------+
| How many AII rooms are in the     |          |          |          |
| health-care setting?              |          |          |          |
+-----------------------------------+----------+----------+----------+
| What ventilation methods are used |          |          |          |
| for AII rooms? (Check all that    |          |          |          |
| apply)                            |          |          |          |
|                                   |          |          |          |
| [Primary (general                 |          |          |          |
| ventilation)]{.underline}:        |          |          |          |
|                                   |          |          |          |
| ο Single-pass heating,            |          |          |          |
| ventilating, and air conditioning |          |          |          |
| (HVAC)                            |          |          |          |
|                                   |          |          |          |
| ο Recirculating HVAC systems      |          |          |          |
|                                   |          |          |          |
| [Secondary (methods to increase   |          |          |          |
| equivalent ACH):]{.underline}     |          |          |          |
|                                   |          |          |          |
| ο Fixed room recirculating units  |          |          |          |
|                                   |          |          |          |
| ο HEPA filtration                 |          |          |          |
|                                   |          |          |          |
| ο UVGI                            |          |          |          |
|                                   |          |          |          |
| ο Other (specify)                 |          |          |          |
| \                                 |          |          |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |          |          |
+-----------------------------------+----------+----------+----------+
| Does your health-care setting     |          |          | Yes No   |
| employ, have access to, or        |          |          |          |
| collaborate with an environmental |          |          |          |
| engineer (e.g., professional      |          |          |          |
| engineer) or other professional   |          |          |          |
| with appropriate expertise (e.g., |          |          |          |
| certified industrial hygienist)   |          |          |          |
| for consultation on design        |          |          |          |
| specifications, installation,     |          |          |          |
| maintenance, and evaluation of    |          |          |          |
| environmental controls?           |          |          |          |
+-----------------------------------+----------+----------+----------+
| Are environmental controls        |          |          | Yes No   |
| regularly checked and maintained  |          |          |          |
| with results recorded in          |          |          |          |
| maintenance logs?                 |          |          |          |
+-----------------------------------+----------+----------+----------+
| Are AII rooms checked daily for   |          |          | Yes No   |
| negative pressure when in use?    |          |          |          |
+-----------------------------------+----------+----------+----------+
| Is the directional airflow in AII |          |          | Yes No   |
| rooms checked daily when in use   |          |          |          |
| with smoke tubes or visual        |          |          |          |
| checks?                           |          |          |          |
+-----------------------------------+----------+----------+----------+
| Are these results readily         |          |          | Yes No   |
| available?                        |          |          |          |
+-----------------------------------+----------+----------+----------+
| What procedures are in place if   | ­­­­­­­­­­­\_\_     |          |          |
| the AII room pressure is not      | \_\_\_\_ |          |          |
| negative?                         | \_\_\_\_ |          |          |
|                                   | \_\_\_\_ |          |          |
|                                   | \_\_\_\_ |          |          |
|                                   | \_\_\_\_ |          |          |
|                                   | \_\_\_\_ |          |          |
|                                   | \_\_\_\_ |          |          |
|                                   | \_\_\_\_ |          |          |
|                                   | \_\_\_\_ |          |          |
+-----------------------------------+----------+----------+----------+
| Do AII rooms meet the recommended |          |          | Yes No   |
| pressure differential of          |          |          |          |
| 0.01-inch water column negative   |          |          |          |
| to surrounding structures?        |          |          |          |
+-----------------------------------+----------+----------+----------+

**8. Respiratory-Protection Program**

+-----------------------------------+----------------------+----------+
| Does your health-care setting     |                      | Yes No   |
| have a written                    |                      |          |
| respiratory-protection program?   |                      |          |
+-----------------------------------+----------------------+----------+
| Which HCWs are included in the    | ο Janitorial staff   |          |
| respiratory protection program?   |                      |          |
| (Check all that apply)            | ο Maintenance or     |          |
|                                   | engineering staff    |          |
| ο Physicians                      |                      |          |
|                                   | ο Transportation     |          |
| ο Mid-level practitioners (NPs    | staff                |          |
| and PAs)                          |                      |          |
|                                   | ο Dietary staff      |          |
| ο Nurses                          |                      |          |
|                                   | ο Students           |          |
| ο Administrators                  |                      |          |
|                                   | ο Others             |          |
| ο Laboratory personnel            | (sp                  |          |
|                                   | ecify)\_\_\_\_\_\_\_ |          |
| ο Contract staff                  | \_\_\_\_\_\_\_\_\_\_ |          |
|                                   |                      |          |
| ο Construction or renovation      | \_                   |          |
| staff                             | \_\_\_\_\_\_\_\_\_\_ |          |
|                                   | \_\_\_\_\_\_\_\_\_\_ |          |
| ο Service personnel               | \_\_\_\_\_\_\_\_\_\_ |          |
|                                   |                      |          |
|                                   | \_                   |          |
|                                   | \_\_\_\_\_\_\_\_\_\_ |          |
|                                   | \_\_\_\_\_\_\_\_\_\_ |          |
|                                   | \_\_\_\_\_\_\_\_\_\_ |          |
|                                   |                      |          |
|                                   | \_                   |          |
|                                   | \_\_\_\_\_\_\_\_\_\_ |          |
|                                   | \_\_\_\_\_\_\_\_\_\_ |          |
|                                   | \_\_\_\_\_\_\_\_\_\_ |          |
|                                   |                      |          |
|                                   | \_                   |          |
|                                   | \_\_\_\_\_\_\_\_\_\_ |          |
|                                   | \_\_\_\_\_\_\_\_\_\_ |          |
|                                   | \_\_\_\_\_\_\_\_\_\_ |          |
+-----------------------------------+----------------------+----------+
| Are respirators used in this      |                      |          |
| setting for HCWs working with TB  |                      |          |
| patients? If yes, include         |                      |          |
| manufacturer, model, and specific |                      |          |
| application (e.g., ABC model 1234 |                      |          |
| for bronchoscopy and DEF model    |                      |          |
| 5678 for routine contact with     |                      |          |
| infectious TB patients).          |                      |          |
|                                   |                      |          |
| [Manufacturer]{.underline}        |                      |          |
| [Model]{.underline} [Specific     |                      |          |
| application]{.underline}          |                      |          |
|                                   |                      |          |
| \_\_\_\_\_\_\_\_\_\_\             |                      |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |                      |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |                      |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |                      |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |                      |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |                      |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |                      |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |                      |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |                      |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |                      |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |                      |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |                      |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |                      |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |                      |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |                      |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |                      |          |
|                                   |                      |          |
| \_\_\_\                           |                      |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |                      |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |                      |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |                      |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |                      |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |                      |          |
+-----------------------------------+----------------------+----------+
| Is annual respiratory-protection  |                      | Yes No   |
| training for HCWs performed by a  |                      |          |
| person with advanced training in  |                      |          |
| respiratory protection?           |                      |          |
+-----------------------------------+----------------------+----------+
| Does your health-care setting     |                      | Yes No   |
| provide initial fit testing for   |                      |          |
| HCWs?                             |                      |          |
|                                   |                      |          |
| If yes, when is it conducted?     |                      |          |
| \_\_\_\_\_\_\_\_\_\_\_\           |                      |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |                      |          |
+-----------------------------------+----------------------+----------+
| Does your health-care setting     |                      | Yes No   |
| provide periodic fit testing for  |                      |          |
| HCWs?                             |                      |          |
|                                   |                      |          |
| If yes, when and how frequently   |                      |          |
| is it conducted?                  |                      |          |
| \_\_\_\_\_\_\_\_\_\_\_\           |                      |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |                      |          |
+-----------------------------------+----------------------+----------+
| What method of fit testing is     |                      |          |
| used? Describe.                   |                      |          |
|                                   |                      |          |
| \_\_\_\_\_\_\_                    |                      |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |                      |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |                      |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |                      |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |                      |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |                      |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |                      |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |                      |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |                      |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |                      |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |                      |          |
+-----------------------------------+----------------------+----------+
| Is qualitative fit testing used?  |                      | Yes No   |
+-----------------------------------+----------------------+----------+
| Is quantitative fit testing used? |                      | Yes No   |
+-----------------------------------+----------------------+----------+

**9. Reassessment of TB risk**

+-----------------------------------------------------------+----------+
| How frequently is the TB risk assessment conducted or     |          |
| updated in the health-care setting?                       |          |
+-----------------------------------------------------------+----------+
| When was the last TB risk assessment conducted?           |          |
+-----------------------------------------------------------+----------+
| What problems were identified during the previous TB risk |          |
| assessment?                                               |          |
|                                                           |          |
| 1)  \_\_\_\_\_\_\_\_\_\_\_\                               |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |
|                                                           |          |
| 2)  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_              |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |
|     \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_              |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |
|                                                           |          |
| 3)  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_              |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |
|     \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_              |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |
|                                                           |          |
| 4)  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_              |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |
|     \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_              |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |
|                                                           |          |
| 5)  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_              |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |
|     \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_              |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |
+-----------------------------------------------------------+----------+
| What actions were taken to address the problems           |          |
| identified during the previous TB risk assessment?        |          |
|                                                           |          |
| 1)  \_\_\_\_\_\_\_\_\_\_\_\                               |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |
|                                                           |          |
| 2)  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_              |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |
|     \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_              |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |
|                                                           |          |
| 3)  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_              |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |
|     \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_              |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |
|                                                           |          |
| 4)  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_              |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |
|     \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_              |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |
|                                                           |          |
| 5)  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_              |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |
|     \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_              |          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |          |
+-----------------------------------------------------------+----------+
| Did the risk classification need to be revised as a       | Yes No   |
| result of the last TB risk assessment?                    |          |
+-----------------------------------------------------------+----------+

\* If the population served by the health-care facility is not
representative of the community in which the facility is located, an
alternate comparison population might be appropriate.

^†^ Test conversion rate is calculated by dividing the number of
conversions among HCWs by the number of HCWs who were tested and had
prior negative results during a certain period (see Supplement,
Surveillance and Detection of *M. tuberculosis* infections in
Health-Care Settings).