DEPARTMENT OF HEALTH SERVICES
Division of Quality Assurance
F-01679 (12/2015)
STATE OF WISCONSIN
Wis. Admin. Code § DHS 105.17(1r)(a-b)

COMMUNICABLE DISEASE / TUBERCULOSIS SCREENING QUESTIONNAIRE

The Department requires that health care agencies or providers screen all health care staff WITHIN 90 DAYS BEFORE DIRECT CONTACT AND PERIODICALLY, to ensure that staff is free of any communicable diseases before coming into contact with clients. This form is intended to provide guidance for providers. Use of this form is optional.

3Care4U
Personal Care Agency: 3Care4U
Address: P.O. Box 1312, Manitowoc, WI 54220
Phone: 920-663-1225 | Fax: 920-614-2004
Email: [email protected]
Name - Employee Completing Form:
COMMUNICABLE DISEASE SCREENING

Are you experiencing any of the following symptoms?

Sore throat
Rash / vesicles on skin
Cold sore
Fever and rash
Fever and respiratory symptoms - cough, runny nose
Drainage from eyes, ears
Skin lesion, cyst, boil
Nausea, vomiting
Diarrhea
Cough lasting more than three weeks
Swollen lymph nodes
Non healing wound
Returned from travel in another country within the last month
CONDITIONS

Have you ever been told by a physician or other health care provider that you have any of the following conditions?

Hepatitis A, B, or C
Tuberculosis
HIV / AIDS
TUBERCULOSIS (TB) SCREENING

Are you experiencing any of the following symptoms?

Persistent coughing
Coughing up bloody sputum or blood
Night sweats
Unexplained fatigue
Fever recurring
Unexplained weight loss
Positive for TB - either skin test or blood test
Have you ever been told by a health care provider that you have had active TB?
Have you ever cared for or lived with anyone diagnosed with active TB?
Have you worked or volunteered in a setting where TB may be more common?

Depending on the responses to the above questions, the registered nurse (RN) reviewing this document may refer you for a follow-up appointment with your physician, nurse practitioner (NP), or physician’s assistant (PA). At this appointment you will receive written documentation that you pose no risk for exposing others to communicable diseases.

I acknowledge that the above information is true and correct to the best of my knowledge.

OFFICE USE ONLY (RN SCREENER)

I have conducted a screening and have reviewed the information on this form. The employee appears to be clinically free from communicable disease and TB.
RN referral to physician, NP, or PA