MVAC

HEAD START VOLUNTEER - TB SCREENING AND TESTING

Program______________________________

HEAD START VOLUNTEER - TB SCREENING AND TESTING

To protect our children, Head Start requests that all regular volunteers be screened for tuberculosis. A regular volunteer is defined as a person who volunteers in the Head Start classroom more than one time per month.

HIGH RISK CRITERIA FOR TUBERCULOSIS

1. A person exhibiting symptoms of TB (cough, cough with bleeding, weight loss, etc.) and/or laboratory findings that suggest TB.

2. A person having recent contact with someone known or suspected to have clinically active TB.

3. A person with HIV infection.

4. A person with abnormal chest x-rays suggesting past TB.

5. A person with other medical conditions that increase the risk of TB. (rapid weight loss, end-stage renal disease, diabetes mellitus, injecting drug use, prolonged corticosteroid therapy, etc.)

6. A person from a high risk group for recent infections with M. tuberculosis, such as immigrants from Asia, Africa, Latin American, and Oceania; and medically underserved populations.

Please check and sign one of the statements below.

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  I have read the High Risk Criteria for Tuberculosis and would not be considered at risk. For personal or medical reasons I choose not to obtain a TB test at this time.

Signature: ____________________________________

Date: ____________________________________

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  I have read the High Risk Criteria and would be considered at risk. I will obtain a TB skin test and provide Head Start with documentation as to the date and results of my most recent TB test.

I understand that I need to obtain this documentation before volunteering in the Head Start classroom.

Signature: ____________________________________

Date: ____________________________________

Medical Provider of TB test: ____________________________________

(a separate release must be signed if you wish us to obtain these results directly from your physician)

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*Head Start will pay for TB screening for Head Start parents who are regular volunteers and have no other medical payment source.