FOOTHILL DE ANZA COMMUNITY COLLEGE DISTRICT Office of Human Resources & Equal Opportunity TUBERCULIN RISK ASSESSMENT/TB TEST FORM

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1 FOOTHILL DE ANZA COMMUNITY COLLEGE DISTRICT Office of Human Resources & Equal Opportunity TUBERCULIN RISK ASSESSMENT/TB TEST FORM To satisfy job-related requirements in the California Education Code and the California Health and Safety Code, all new employees and those with expired TB certificate are required to have a Tuberculosis Risk Assessment and, if necessary, a Skin Test (TST) and any follow-up completed. Kaiser Occupational Health Center offers the Assessment and TST free of charge. Please contact their office concerning dates/times of testing: Kaiser Cupertino/ Santa Clara at Those employees who test positive with a TST must have a chest x-ray to rule out active Tuberculosis. Kaiser will refer the employee to the appropriate medical facility for treatment and follow-up. Those employees who have previously tested positive are required to provide evidence of the positive TST followed by a negative chest x-ray. Such evidence shall be taken in person to their office for assessment. Instructions: If you are doing the test at Kaiser Occupational Health Center at Cupertino/Santa Clara, please print and bring page 7 with you when visiting their office. You may also do the test at your own physician; however, please do keep in mind we will not reimburse the cost of TB Testing/Assessment if it is completed outside the Kaiser Occupational Health Center at Cupertino/Santa Clara. If you choose to go with your own physician, please have your health provider sign/complete page 1-3 of this form. PLEASE TAKE THIS FORM WITH YOU WHEN YOU HAVE YOUR TUBERCULOSIS RISK ASSESSMENT TEST TAKEN. To be completed by employee: (Print) Last Name First Name Phone # CWID# To be completed by Health Care Provider: CERTIFICATION OF TUBERCULOSIS EXAMINATION AND REPORT: Tuberculosis Risk Assessment Certificate of Completion attached. No additional examination necessary. TST: Negative (millimeter) Positive (millimeter) Date Give: Date Read: QUANTIFERON TB GOLD Negative Positive Indeterminate Date: Clinical Notations: SURVELLANCE/SYMPTOMS REVIEW FORM: Negative Positive Date: CHEST X-RAY Negative Positive Date: OTHER: Follow-up: Yes No Signature of Health Care Provider Please return results/ certificate to: Foothill De Anza Community College District Office of Human Resources & Equal Opportunity Attn: Keisha Sentosa El Monte Road Los Altos Hills, CA Date: Date: REVISED Sept 2017

2 School Staff & Volunteers: Tuberculosis Risk Assessment Job-related requirement for child care, pre-k, K-12, and community colleges The purpose of this tool is to identify adults with infectious tuberculosis (TB) to prevent them from spreading TB. Use of this risk assessment is required in the California Education Code, Sections and and the California Health and Safety Code, Sections and , , and The law requires that a health care provider administer this risk assessment. A health care provider, as defined for this purpose, is any organization, facility, institution or person licensed, certified or otherwise authorized or permitted by state law to deliver or furnish health services. Any person administering this risk assessment is to have training in the purpose and significance of the risk assessment and Certificate of Completion. Name of Employee/Volunteer Assessed for TB Risk Factors: Assessment Date: Date of Birth: History of Tuberculosis Infection or Disease (Check appropriate box below) Yes If there is a documented history of positive TB test (infection) or TB disease, then a symptom review and chest x-ray (if none performed in previous 6 months) should be performed at initial hire by a physician, physician assistant, or nurse practitioner. Once a person has a documented positive test for TB infection that has been followed by an x-ray that was determined to be free of infectious TB, the TB risk assessment (and repeat x-rays) is no longer required. If an employee or volunteer becomes symptomatic for TB, then he/she should seek care from his/her health care provider. No (Assess for Risk Factors for Tuberculosis using box below) Risk Factors for Tuberculosis (Check appropriate boxes below) If any of the 5 boxes below are checked, perform a Mantoux tuberculin skin test (TST) or Interferon Gamma Release Assay (IGRA). Re-testing with TST or IGRA should only be done in persons who previously tested negative, and have new risk factors since the last assessment. A positive TST or IGRA should be followed by a chest x-ray, and if normal, treatment for TB infection considered. (Centers for Disease Control and Prevention [CDC]). Latent Tuberculosis Infection: A Guide for Primary Health Care Providers. 2013) One or more signs and symptoms of TB: prolonged cough, coughing up blood, fever, night sweats, weight loss, excessive fatigue. Evaluate for active TB disease with a TST or IGRA, chest x-ray, symptom screen, and if indicated, sputum acid-fast bacilli (AFB) smears, cultures and nucleic acid amplification testing. A negative TST or IGRA does not rule out active TB disease. Close contact to someone with infectious TB disease at any time Foreign-born person from a country with an elevated TB rate Includes any country other than the United States, Canada, Australia, New Zealand, or a country in western or northern Europe. IGRA is preferred over TST for foreign-born persons Consecutive travel or residence of 1 month in a country with an elevated TB rate Includes any country other than the United States, Canada, Australia, New Zealand, or a country in western or northern Europe. Volunteered, worked or lived in a correctional or homeless facility TCB-01 (10/2016)

3 Certificate of Completion Tuberculosis Risk Assessment and/or Examination To satisfy job-related requirements in the California Education Code, Sections and and the California Health and Safety Code, Sections , , and First and Last Name of the person assessed and/or examined: Date of assessment and/or examination: mo./ day/ yr. Date of Birth: mo./ day/ yr. The above named patient has submitted to a tuberculosis risk assessment. The patient does not have risk factors, or if tuberculosis risk factors were identified, the patient has been examined and determined to be free of infectious tuberculosis. X Signature of Health Care Provider completing the risk assessment and/or examination Please print, place label or stamp with Health Care Provider Name and Address (include Number, Street, City, State, and Zip Code): Telephone and FAX: TCB-01 (10/2016)

4 School Staff & Volunteers: Tuberculosis Risk Assessment User Guide Job-related requirement for child care, pre-k, K-12, and community colleges Background California law requires that school staff working with children and community college students be free of infectious tuberculosis (TB). These updated laws reflect current federal Centers for Disease Control and Prevention (CDC) recommendations for targeted TB testing. Enacted laws, AB 1667, effective on January 1, 2015, SB 792 on September 1, 2016, and SB 1038 on January 1, 2017, require a tuberculosis (TB) risk assessment be administered and if risk factors are identified, a TB test and examination be performed by a health care provider to determine that the person is free of infectious tuberculosis. The use of the TB risk assessment and the Certificate of Completion, developed by the California Department of Public Health (CDPH) and California TB Controllers Association (CTCA) are also required. AB 1667 impacted the following groups on 1/1/2015: 1. Persons employed by a K-12 school district, or employed under contract, in a certificated or classified position (California Education Code, Section 49406) 2. Persons employed, or employed under contract, by a private or parochial elementary or secondary school, or any nursery school (California Health and Safety Code, Sections and ). 3. Persons providing for the transportation of pupils under authorized contract in public, charter, private or parochial elementary or secondary schools (California Education Code, Section and California Health and Safety Code, Section ). 4. Persons volunteering with frequent or prolonged contact with pupils (California Education Code, Section and California Health and Safety Code, Section ). SB 792 impacted the following group on 9/1/2016: Persons employed as a teacher in a child care center (California Health and Safety Code Section ). SB 1038 impacts the following group on 1/1/2017: Persons employed by a community college district in an academic or classified position (California Education Code, Section ). Testing for latent TB infection (LTBI) Because an interferon gamma release assay (IGRA) blood test has increased specificity for TB infection in persons vaccinated with BCG, IGRA is preferred over the tuberculin skin test (TST) in these persons. Most persons born outside the United States have been vaccinated with BCG. Repeat risk assessment and testing If there is a documented history of positive TB test or TB disease, then a symptom review and chest x-ray should be performed at initial hire. Once a person has a documented positive test for TB infection that has been followed by a chest x-ray (CXR) that was determined to be free of infectious TB, the TB risk assessment (and repeat x-rays) is no longer required. Repeat risk assessments should occur every four years (unless otherwise required) to identify any additional risk factors, and TB testing based on the results of the TB risk assessment. Re-testing should only be done in persons who previously tested negative, and have new risk factors since the last assessment. Previous or inactive tuberculosis Persons with a previous chest radiograph showing findings consistent with previous or inactive TB should be tested for LTBI. In addition to LTBI testing, evaluate for active TB disease. Negative test for LTBI does not rule out TB disease It is important to remember that a negative TST or IGRA result does not rule out active TB disease. In fact, a negative TST or IGRA in a person with active TB can be a sign of extensive disease and poor outcome. Symptoms of TB should trigger evaluation for active TB disease Persons with any of the following symptoms that are otherwise unexplained should be medically evaluated: cough for more than 2-3 weeks, fevers, night sweats, weight loss, hemoptysis. TB infection treatment is recommended Shorter regimens for treating LTBI have been shown to be as effective as 9 months of isoniazid, and are more likely to be completed. Shorter regimens are preferred in most situations. Drug-drug interactions and contact to drug resistant TB are frequent reasons these regimens cannot be used. Please consult with your local public health department on any other recommendations and mandates that should also be considered. BCG=Bacillus Calmette-Guérin; TST= tuberculin skin test; IGRA= Interferon gamma release assay (e.g., QuantiFERON-TB Gold, T-SPOT.TB) October 24, 2016

5 Kaiser On-the-Job Kaiser Permanente Occupational Health Services are available to all employees, not just our members. Emergency and non-life-threatening care If you have an emergency medical condition, call 911 or go to the nearest hospital. An emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a reasonable person would have believed that the absence of immediate medical attention would result in any of the following: (1) placing the person s health (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; (2) serious impairment to bodily functions; or (3) serious dysfunction of any bodily organ or part. A mental health condition is an emergency medical condition when it meets the requirements of the paragraph above or, for members who are not enrolled in Kaiser Permanente Senior Advantage, when the condition manifests itself by acute symptoms of sufficient severity such that either of the following is true: the person is an immediate danger to himself or herself or to others, or the person is immediately unable to provide for, or use, food, shelter, or clothing, due to the mental disorder. For a non-life-threatening, work-related injury or illness, follow two simple steps: 1. Inform your supervisor of your work-related injury or illness as soon as possible. 2. Call the Kaiser On-the-Job Occupational Health Center nearest you. To locate the nearest center, call KOJ-WORK ( ), or refer to the appropriate page in this guide. If you ve designated a provider as your occupational health physician, please follow the appropriate guidelines for accessing non-lifethreatening care for work-related injuries and illnesses. Cupertino DEDICATED OCCUPATIONAL HEALTH CENTER N. Wolfe Road, Suite SW1-190 Cupertino, CA HOSPITAL SERVICES/AFTER-HOURS CARE 700 Lawrence Expressway, Dept. 100 Santa Clara, CA Hours M-F, 8:30 a.m. 5 p.m.* Hours 7 days a week, 24 hours Homestead Rd Miller Ave N Wolfe Rd Lawrence Expwy Kiely Blvd Stevens Creek Blvd 280 Map not to scale Saratoga Ave N Cupertino/Santa Clara * Holidays closed: Martin Luther King Jr. Day; Presidents Day; Memorial Day; Independence Day; Labor Day; Thanksgiving Day and day after Thanksgiving. Please call for hours during the weeks of Christmas and New Year s. kp.org

6 Kaiser On-the-Job Los Servicios para la Salud Ocupacional de Kaiser Permanente se ofrecen a todos los empleados, no sólo a nuestros miembros. Atención de emergencia y en casos sin riesgo de muerte Si tiene un problema médico de emergencia, llame al 911 o vaya al hospital más cercano. Un problema médico de emergencia es un problema médico que se manifiesta con síntomas agudos de tal gravedad, incluido el dolor intenso, que una persona razonable pudiera creer que no recibir atención médica inmediata resultaría en una de estas situaciones: (1) poner la salud de la persona (o, en el caso de una mujer embarazada, la salud de ella o de su hijo aún no nacido) en grave peligro; (2) causar graves problemas en las funciones corporales; o (3) ocasionar la disfunción grave de algún órgano o parte del cuerpo. Se considera que una afección de salud mental es un problema médico de emergencia cuando reúne los requisitos del párrafo anterior o, en el caso de los miembros que no están inscritos en el plan Kaiser Permanente Senior Advantage, cuando el problema médico se manifiesta con síntomas agudos de suficiente gravedad que una de estas situaciones es válida: la persona representa un peligro inmediato en contra de sí misma o de terceros, o bien la persona no puede hacer inmediatamente arreglos para proveer alimentación, casa o vestido ni para usarlos debido a un trastorno mental. En el caso de una lesión o enfermedad ocupacional sin riesgo de muerte, siga dos sencillos pasos: 1. Informe lo más pronto posible a su supervisor de la lesión o enfermedad ocupacional. 2. Llame al Centro de Salud Ocupacional Kaiser-On-the-Job más cercano. Para encontrar el centro más cercano, llame al , o consulte la página apropiada en esta guía. Si ha designado a un proveedor como su médico de salud ocupacional, por favor siga las pautas apropiadas para recibir atención en casos sin riesgo de muerte para lesiones y enfermedades ocupacionales. Cupertino CENTRO DEDICADO A SERVICIOS PARA LA SALUD OCUPACIONAL Mapa no a escala N. Wolfe Road, Suite SW1-190 Cupertino, CA Lawrence Expressway, Departamento 100 Santa Clara, CA Horario lunes a viernes, de 8:30 a. m. a 5 p. m.* SERVICIOS HOSPITALARIOS/ATENCIÓN DESPUÉS DEL HORARIO NORMAL Horario los 7 días de la semana, las 24 horas Homestead Rd Miller Ave N Wolfe Rd Lawrence Expwy Kiely Blvd Stevens Creek Blvd 280 Cupertino/Santa Clara Saratoga Ave N * Cerrado los días festivos: Martin Luther King Jr. Day; Presidents Day; Memorial Day; Independence Day; Labor Day; Thanksgiving Day y el día después de Thanksgiving. Llame para consultar el horario durante las semanas de Navidad y Año Nuevo. kp.org Please recycle November 2015

7 Occupational Health and Safety Services Referral Form Please complete and fax this form to the clinic location where services are to be provided. To inquire about appointment availability or to change or cancel an appointment, please call the Occupational Health Clinic and ask for the OHSS service representative or a clinic staff member. Clinic Location: Phone: Company Name: Department/Location: Company Contact for results/questions: Date: Fax: Foothill De Anza Community College District Keisha Sentosa Phone: (650) Fax: (650) Employee Name: Kaiser MR# If Kaiser MR# not available, please provide the following: Address: Home Phone: SS#: (last 4 digits only) Maiden Name (when applicable) Work Phone: Date of Birth: Gender: Male Female Job Title: Services Requested Non Preplacement Services: (PPD/TB) - TB Clearance TB Risk Assessment (per Ed Code) Other services may be provided and billed at the physician/clinician s discretion to give clearance on an applicant/employee as identified in your Letter of Agreement (LOA) under the As Clinically Indicated section of that visit category. If other screening/testing is needed and is not outlined in the LOA, we will call for authorization. Preferred date and/or timeframe for appointment: APPT IS SCHEDULED FOR: Comments/Additional Requests: For clinic use only: 1 st attempt for notification to employee: Date: Time: Initials: 2nd attempt for notification to employee: Date: Time: Initials: 3rd attempt for notification to employee: Date: Time: Initials: