TUBERCULOSIS QUESTIONNAIRE
Name______________________ Date of Birth __________________ Student Banner ID (U#) ________________________SECTION ONE: Please answer the following questions.
1. Have you traveled to or lived in Africa, Asia (excluding Japan), Caribbean Nations, Central/South America, Eastern
Europe, India, Middle East, Portugal, or The South Pacific (excluding Australia and New Zealand) for more than 4weeks?
YESNO
If so, where?
2. Have you been a resident, employee, or volunteer in a prison, homeless shelter, hospital, nursing home, or other long-term
treatment facility?
YESNO
3. Do you have AIDS/HIV or take immunosuppressive medication such as prednisone, chemotherapy, or biologics?
YES
NO
4. Do you have a personal history of cancer, leukemia, kidney disease, diabetes, alcoholism, or intravenous drug use?
YESNO
5. Have you ever had close contact with persons known or suspected to have active TB disease?
YESNO
If the answer to all the above questions is NO, no TB testing or further action is required.
If the answer is YES to any of the questions above, SULC requires that you receive TB testing. The PPD skin test must bedone within 12 months prior to beginning your classes. You can obtain the PPD skin test from your local health care provider.
(See SECTION TWO below)
International Students Only: Tuberculosis skin testing is mandatory and must be done in the United States. If you have beentreated and or vaccinated for TB, please bring your English translated medical records.
SECTION TWO: Test Results
Step 1: Tuberculin Skin Test – Positive if  10mm for questions 1, 2, or 3 or  5mm for questions 4 or 5.
Date Given: _________ Date Read: ________ Result: ________mm of Induration Interpretation: Positive_______ Negative _______

Step 2: A QFT or T-SPOT is required if PPD is positive. A Chest X-Ray will not be accepted in its place.
(Please provide a copy of results.)
Date Given: _________ Circle Method Given: QFT T-SPOT Result: Positive_______ Negative _______

Step 3: Students with a positive QFT or T-Spot should receive a Chest X-Ray.
Date of X-ray: _________ Result: Normal_______ Abnormal_______

Step 4: Students with a positive QFT or T-SPOT with no signs of active disease on chest x-ray are recommended
to be treated for Latent TB with appropriate medication
Name of Medications for treatment:______ Date Initiated and Duration of treatment:_____ (please provide copy of completion of treatment).
________ Student has been treated or agrees to receive treatment________ Student declines treatment at this time and agrees to come into the Student Health Center to sign the “Refusal of Treatment for LatentTB”. Student also agrees to routine checkups to monitor progression of Latent TB.

Health Care Provider’s Name, Address, Phone #: _________________________________________________________
Health Care Provider’s Signature:_______________________________________ Date:__________________________Southern University Law Center
Admission and Recruitment Department
P.O. Box 9294
Baton Rouge, Louisiana 70813
Phone: (225) 771-6297 / Fax: (225) 771-2372
IMPORTANT: Make a copy of this form for your personal records.
NOTE: You will not be permitted to register until all immunization records are in compliance.