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Tuberculosis Risk Questionnaire

1. To the best of your knowledge have you ever had close contact with anyone who was sick with tuberculosis (TB)?

2. Were you born in one of the countries listed below*?

3. Have you traveled or lived for more than one month in one or more of the countries listed below*?

If the answer to any of the above questions is YES, the Massachusetts Department of Public Health strongly recommends that you have a tuberculin skin test to check for latent tuberculosis infection.

If the answer to all of the above questions is NO, a tuberculin skin test should not be done.

*Please note: If you have had a positive tuberculin skin test in the past, you do not need another test. If you had the BCG vaccine in the past a simple blood test may be more appropriate for you.

Please contact UHCS if you would like to schedule a tuberculin skin test or the TB blood test.

COUNTRIES WITH HIGH RATES OF TUBERCULOSIS (TB)*

Afghanistan Colombia India Moldova, Rep. Senegal

Angola Comoros Indonesia Mongolia Sierra Leone

Armenia Congo Iran Morocco Solomon Islands

Azerbaijan Congo, DR Iraq Mozambique Somalia

Bahamas Cote d'Ivoire Kazakhstan Myanmar South Africa

Bahrain Croatia Kenya Namibia Sri Lanka

Bangladesh Djibouti Kiribati Nepal Sudan

Belarus Dominican Rep. Korea, DPR New Caledonia Suriname

Benin Ecuador Korea, Rep. Nicaragua Swaziland

Bhutan El Salvador Kyrgyzstan Niger Syrian Arab Rep.

Bolivia Equatorial Guinea Lao PDR Nigeria Tajikistan

Bosnia & Herzegovina Eritrea Latvia Niue Tanzania, UR

Botswana Estonia Lesotho Northern Mariana Islands Thailand

Brazil Ethiopia Liberia Pakistan Togo

Brunei Darussalam Gabon Lithuania Palau Tokelau

Burkina Faso Gambia Macedonia, TFYR Panama Turkmenistan

Burundi Georgia Madagascar Papua New Guinea Uganda

Cambodia Ghana Malawi Paraguay Ukraine

Cameroon Guam Malaysia Peru Uzbekistan

Cape Verde Guatemala Maldives Philippines Vanuatu

Central African Rep. Guinea Mali Portugal Vietnam

Chad Guinea-Bissau Marshall Islands Romania Yemen

China Guyana Mauritania Russian Federation Zambia

China, Hong Kong SAR Haiti Mauritius Rwanda Zimbabwe

China, Macao SAR Honduras Micronesia Sao Tome & Principe

* World Health Organization. Global tuberculosis control. WHO report 2002.