ࡱ> PRO; bjbj%% 8<GdGd & & kkkkk8$g)h_PL(((((((($+.& )k )kk!) Fkk( ( V'@v(P`; j' (7)0g)'x/t/v(v(/k(H  ) )2 g)/& 1: TB Risk Assessment Questionnaire* Name: __________ DOB: Last tuberculin skin test (TST) or IGRA blood test date: ____ Results: ( mm induration for TST)  FORMCHECKBOX  not read by health care professional If positive TST / IGRA result in the past: Chest radiograph date and result: ____________ Treatment details: Was your child born outside the United States?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, country:_______________Since your childs TB skin test / blood test, has your child traveled outside the U.S.?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Country or countries visited:  Dates of travel/how long did they travel? ______ Where did they stay (hotel, family, resort)? Since the last TB skin / blood test, has your child been around anyone with TB?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Nature of their TB disease? Positive skin / blood test result with normal chest x-ray taking one medicine or no treatment OR TB disease taking many pills and different kinds of medicine? Name of person: ____ Date of birth: _____ Where is the person being treated? Since their last skin / blood test, has your child had close contact with a person who has a positive TB test result?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Nature of their TB disease? Positive skin / blood test result with normal chest X ray taking medicine or no treatment OR TB disease taking many pills and different kinds of medicine? Name of person: ___ Date of birth:  Where is the person being treated? _______Optional questions depending on local epidemiology:Since their last test, has your child had unpasteurized milk or cheese (from Mexico or Central America)?Since their last test, has your child been around people in jail, people who are homeless or in shelters, people who have HIV, or use illegal drugs?Since their last test, has your child lived with a new person who was born or traveled outside the U.S.?INSTRUCTIONS for PROVIDERS: Test only children who have a new risk factor since their last TST / IGRAIf the child has previously had a positive TST / IGRA result, do not administer another TST / IGRA.Significant travel is considered travel to a country with a high prevalence of TB (e.g., in Africa, Asia, Latin America, and Eastern Europe) for >1 week AND had substantial contact with indigenous people from such countries (did not stay in a resort). *See also:  HYPERLINK "https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/TBCB-CA-Pediatric-TB-Risk-Assessment.pdf" California Tuberculosis Pediatric Risk Assessment and User Guide     PAGE  From Pediatric Tuberculosis: An Online Presentation by Ann Loeffler, MD. Produced by the Curry International Tuberculosis Center. Rev 6-11-18  !#*589@EFIh|6 > D E F G [ h i k j0hHUjhHUhHOJQJ^JaJjhHUjhHU h%3>* h J>* hH>*h%3 hHCJhK K5>*\hH5>*\ hH5\h JhH:"#$9:EFGHoJkdP$$Ifl0,+ +64 layt_q$If:kd$$Ifl4,+++64 laf4yt_q$If HIE e_$IfJkdt$$Ifl0,+ +64 layt_q$IfJkd$$Ifl0,+ +64 layt_qE F G h i j k E:kdl$$Ifl4,+++64 laf4yt_q:kd$$Ifl4,+++64 laf4yt_q$If$If:kd$$Ifl4,+++64 laf4yt_qk v w x>:kd,$$Ifl4,+++64 laf4yt_q:kd$$Ifl4,+++64 laf4yt_q$If:kd$$Ifl4,+++64 laf4yt_q & F$IfgdH  # @ A B C G H V W X ^ ` a o p q    / 7 R g j k y z {    0 2 p r s t u h J>* h JCJhHKHOJQJaJj0hHUjhHU hHCJ hH>*jhHUjDhHUjhHUh Jh%3hHxx:kd$$Ifl4,+++64 laf4yt_q$If:kd$$Ifl4,+++64 laf4yt_q & F$IfgdH:kdl$$Ifl4,+++64 laf4yt_qq r s t u |||| $Ifgd J:kd$$Ifl4,+++64 laf4yt_q$If:kdD$$Ifl4,+++64 laf4yt_q U V d e f o p ~  DEU]^nuvwNP#$뵫٫도hK KhK KCJ aJ hK K h J5\hK K56\] h J6]h J56\] h JCJ jV h JUj h JUjh JU h JCJh JOJQJ^JaJh J h JCJ h J>* hK K>*4 f:kdB $$Ifl4,+++64 laf4yt_q $Ifgd J $Ifgd JMkd$$Ifl40,+ +64 laf4yt_q ~uu $Ifgd J:kd $$Ifl4,+++64 laf4yt_q & F$Ifgd J:kd $$Ifl4,+++64 laf4yt_q CDEo5:kd $$Ifl4,+++64 laf4yt_q:kdx $$Ifl4,+++64 laf4yt_q $Ifgd JMkd $$Ifl40,+ +64 laf4yt_qE]^uvwo:kdv $$Ifl4,+++64 laf4yt_qMkd $$Ifl40,+ +64 laf4yt_q $Ifgd JMNu;u:kdf $$Ifl4,+++64 laf4yt_q & F$Ifgd J:kd $$Ifl4,+++64 laf4yt_q $Ifgd J:kd $$Ifl4,+++64 laf4yt_qMNOP~u;u:kdV$$Ifl4,+++64 laf4yt_q $Ifgd J:kd$$Ifl4,+++64 laf4yt_q & F$Ifgd J:kd $$Ifl4,+++64 laf4yt_q~qh $IfgdK K $If^gdK K:kd$$Ifl4,+++64 laf4yt_q & F$Ifgd J:kd$$Ifl4,+++64 laf4yt_q$% @fgms㭩}tnnh h/CJ h JCJhH6CJ] h_qCJ hHCJ hH0JjhH0JUhHhijhiUh JhK K3hK KhK K0J5B* CJOJQJ\^JaJphf/hK KhK K5B*CJOJQJ\^JaJph"""8jhK KhK K5B*CJOJQJU\^JaJph"""$  !00]0^0h]h&`#$0^0$a$gd2J:kdF$$Ifl4,+++64 laf4yt_q$a$gd2Jh]h  !0]^06&P1h:p J/ =!"#$% N$$If!vh#v+:V l4+65+4f4yt_qV$$If!vh#v #v:V l+65 54yt_qV$$If!vh#v #v:V l+65 54yt_qtDeCheck9V$$If!vh#v #v:V l+65 54yt_qN$$If!vh#v+:V l4+65+4f4yt_qN$$If!vh#v+:V l4+65+4f4yt_qN$$If!vh#v+:V l4+65+4f4yt_qtDeCheck1tDeCheck2N$$If!vh#v+:V l4+65+4f4yt_qN$$If!vh#v+:V l4+65+4f4yt_qtDeCheck3tDeCheck4N$$If!vh#v+:V l4+65+4f4yt_qN$$If!vh#v+:V l4+65+4f4yt_qN$$If!vh#v+:V l4+65+4f4yt_qN$$If!vh#v+:V l4+65+4f4yt_qN$$If!vh#v+:V l4+65+4f4yt_qtDeCheck5tDeCheck6N$$If!vh#v+:V l4+65+4f4yt_qN$$If!vh#v+:V l4+65+4f4yt_qN$$If!vh#v+:V l4+65+4f4yt_qN$$If!vh#v+:V l4+65+4f4yt_q\$$If!vh#v #v:V l4+65 54f4yt_qN$$If!vh#v+:V l4+65+4f4yt_qN$$If!vh#v+:V l4+65+4f4yt_qtDeCheck7tDeCheck8N$$If!vh#v+:V l4+65+4f4yt_q\$$If!vh#v #v:V l4+65 54f4yt_qN$$If!vh#v+:V l4+65+4f4yt_qN$$If!vh#v+:V l4+65+4f4yt_q\$$If!vh#v #v:V l4+65 54f4yt_qN$$If!vh#v+:V l4+65+4f4yt_qN$$If!vh#v+:V l4+65+4f4yt_qN$$If!vh#v+:V l4+65+4f4yt_qN$$If!vh#v+:V l4+65+4f4yt_qN$$If!vh#v+:V l4+65+4f4yt_qN$$If!vh#v+:V l4+65+4f4yt_qN$$If!vh#v+:V l4+65+4f4yt_qN$$If!vh#v+:V l4+65+4f4yt_qN$$If!vh#v+:V l4+65+4f4yt_qN$$If!vh#v+:V l4+65+4f4yt_q$w666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH66666666666666666666666666666666666666666666666666666666666666666p62&6FVfv2(&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@6666_HmH nH sH tH @`@ NormalCJ_HaJmH sH tH <<  Heading 1$@&]@@  Heading 2$d@&5\>@>  Heading 3$@& 5CJ$\DA`D Default Paragraph FontVi@V 0 Table Normal :V 44 la (k ( 0No List H@H  Balloon TextCJOJQJ^JaJ:B:  Body Text ]\8/8 titles-title15\L/!L bibrecord-highlight1 5\ph2/12 titles-pt1ph:/A: titles-source16]0U`Q0  Hyperlink>*B*DObD wfxRecipientKHOJQJaJ.X q. Emphasis6]FV F FollowedHyperlink >*B* phXCX Body Text Indent ^CJOJQJ^JaJ:>@: Title$a$5CJ\aJ4 @4 Footer  !.)@.  Page NumberRPR  Body Text 2$da$6B*]aJph3334@4 Header  !B' B %30Comment ReferenceCJaJ<< !%30 Comment Text CJaJ::  %30Comment Text Char@j@ #%30Comment Subject"5\F/1F "%30Comment Subject Char5\PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭VGRU1a$N% ʣꂣKЛjVkUDRKQj/dR*SxMPsʧJ5$4vq^WCʽ D{>̳`3REB=꽻Ut Qy@֐\.X7<:+& 0h @>nƭBVqu ѡ{5kP?O&Cנ Aw0kPo۵(h[5($=CVs]mY2zw`nKDC]j%KXK 'P@$I=Y%C%gx'$!V(ekڤք'Qt!x7xbJ7 o߼W_y|nʒ;Fido/_1z/L?>o_;9:33`=—S,FĔ觑@)R8elmEv|!ո/,Ә%qh|'1:`ij.̳u'k CZ^WcK0'E8S߱sˮdΙ`K}A"NșM1I/AeހQתGF@A~eh-QR9C 5 ~d"9 0exp<^!͸~J7䒜t L䈝c\)Ic8E&]Sf~@Aw?'r3Ȱ&2@7k}̬naWJ}N1XGVh`L%Z`=`VKb*X=z%"sI<&n| .qc:?7/N<Z*`]u-]e|aѸ¾|mH{m3CԚ .ÕnAr)[;-ݑ$$`:Ʊ>NVl%kv:Ns _OuCX=mO4m's߸d|0n;pt2e}:zOrgI( 'B='8\L`"Ǚ 4F+8JI$rՑVLvVxNN";fVYx-,JfV<+k>hP!aLfh:HHX WQXt,:JU{,Z BpB)sֻڙӇiE4(=U\.O. +x"aMB[F7x"ytѫиK-zz>F>75eo5C9Z%c7ܼ%6M2ˊ 9B" N "1(IzZ~>Yr]H+9pd\4n(Kg\V$=]B,lוDA=eX)Ly5ot e㈮bW3gp : j$/g*QjZTa!e9#i5*j5ö fE`514g{7vnO(^ ,j~V9;kvv"adV݊oTAn7jah+y^@ARhW.GMuO "/e5[s󿬅`Z'WfPt~f}kA'0z|>ܙ|Uw{@՘tAm'`4T֠2j ۣhvWwA9 ZNU+Awvhv36V`^PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!g theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] +<  $ HE k w  q E GW`pjzUeo$ G G G G$G$G$G$G$G$Xt!8@0(  B S  ? Check9Check1Check2Check3Check4Check5Check6Check7Check8HakVp Xq{f w 33358 58 f g m s q|5z_rJhc<h hh^h`OJQJo(oh 88^8`OJQJo(oh ^`OJQJo(h   ^ `OJQJo(h   ^ `OJQJo(oh xx^x`OJQJo(h HH^H`OJQJo(h ^`OJQJo(oh ^`OJQJo( hh^h`56o(.^`.pLp^p`L.@ @ ^@ `.^`.L^`L.^`.^`.PLP^P`L.h^`.h^`.hpLp^p`L.h@ @ ^@ `.h^`.hL^`L.h^`.h^`.hPLP^P`L._q|5hc         ߈                 [g  /F JK K_qn_{C,iH2Ji%3 @  X@Unknown G*Ax Times New Roman5Symbol3. *Cx Arial5..[`)TahomaA. Arial NarrowC.,{ @Calibri Light7.@Calibri?= *Cx Courier New;WingdingsA$BCambria Math"hn[f'n[f'cD D !20  KqHP  $P%32! xxe* eTuberculosis (TB) is a bacterial infection which causes significant worldwide morbidity and mortalityAnn M. Loeffler Kay Wallis   Oh+'04@L\ p|    hTuberculosis (TB) is a bacterial infection which causes significant worldwide morbidity and mortalityAnn M. LoefflerNormal Kay Wallis2Microsoft Office Word@F#@Ϥ@g4@g4D ՜.+,D՜.+,` hp  BMicrosoft Corporation  fTuberculosis (TB) is a bacterial infection which causes significant worldwide morbidity and mortality TitleT 8@ _PID_HLINKSA Vihttps://www.cdph.ca.gov/Programs/CID/DCDC/CDPH Document Library/TBCB-CA-Pediatric-TB-Risk-Assessment.pdf  !"#$%&()*+,-./0123456789:;<=>@ABCDEFHIJKLMNQRoot Entry Fa;SData 1Table'/WordDocument8<SummaryInformation(?DocumentSummaryInformation8GCompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q