Use of this questionnaire is required by California Education Code sections 49406 and 87408.6, and Health and Safety Code sections 1597.055 and 121525-121555.^
The purpose of this tool is to identify adults with infectious tuberculosis (TB) to prevent them from spreading disease.
Do not repeat testing unless there are new risk factors since the last negative test.
Do not treat for latent TB infection (LTBI) until active TB disease has been excluded:
For individuals with signs or symptoms of TB disease or abnormal chest x-ray consistent with TB disease, evaluate for active TB disease with a chest x-ray, symptom screen, and if indicated, sputum AFB smears, cultures and nucleic acid amplification testing.
A negative tuberculin skin test (TST) or interferon gamma release assay (IGRA) does not rule out active TB disease.

Name of Person Assessed for TB Risk Factors: 	
Assessment Date: 		Date of Birth: 	

History of Tuberculosis Disease or Infection (Check appropriate box below)	
Yes
If there is a documented history of positive TB test or TB disease, then a symptom review and chest x-ray (if none performed in
the previous 6 months) should be performed at initial hire by a physician, physician assistant, or nurse practitioner. If the x-ray does not have evidence of TB, the person is no longer required to submit to a TB risk assessment or repeat chest x-rays.	
	No (Assess for Risk Factors for Tuberculosis using box below)	

TB testing is recommended if any of the 3 boxes below are checked	
One or more sign(s) or symptom(s) of TB disease
TB symptoms include prolonged cough, coughing up blood, fever, night sweats, weight loss, or excessive fatigue.	
Birth, travel, or residence in a country with an elevated TB rate for at least 1 month
Includes countries other than the United States, Canada, Australia, New Zealand, or Western and North European countries.
Interferon gamma release assay (IGRA) is preferred over tuberculin skin test (TST) for non-US-born persons.	
	Close contact to someone with infectious TB disease during lifetime	
Treat for LTBI if TB test result is positive and active TB disease is ruled out	
^The law requires that a health care provider administer this questionnaire. 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. A Certificate of Completion should be completed after screening is completed (page 3).

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 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 California School Employee 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:
Persons employed by a K-12 school district, or employed under contract, in a certificated or classified position (California Education Code, Section 49406)
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 121525 and 121555).
Persons providing for the transportation of pupils under authorized contract in public, charter, private or parochial elementary or secondary schools (California Education Code, Section 49406 and California Health and Safety Code, Section 121525).
Persons volunteering with frequent or prolonged contact with pupils (California Education Code, Section 49406 and California Health and Safety Code, Section 121545).
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 1597.055).
SB 1038 impacted the following group on 1/1/2017: Persons employed by a community college district in an academic or classified position (California Education Code, Section 87408.6).
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.

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.
Most patients with LTBI should be treated
Because testing of persons at low risk of LTBI should not be done, persons that test positive for LTBI should generally be treated once active TB disease has been ruled out. However, clinicians should not be compelled to treat low risk persons with a positive test for LTBI.
Emphasis on short course for treatment of LTBI
Shorter regimens for treating LTBI have been shown to be more likely to be completed and the 3 month 12-dose regimen has been shown to be as effective as 9 months of isoniazid. Use of these shorter regimens is preferred in most patients. Drug-drug interactions and contact to drug resistant TB are typical reasons these regimens cannot be used.
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.
Please consult with your local public health department on any other recommendations and mandates that should also be considered.

Certificate of Completion Tuberculosis Risk Assessment and/or Examination
To satisfy job-related requirements in the California Education Code, Sections 49406 and 87408.6 and the California Health and Safety Code, Sections 1597.055, 121525, 121545 and
121555.
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):

California law requires that school staff working with children and community college students be free of infectious tuberculosis (TB). These updated laws reflect current recommendations for targeted TB testing from the federal Centers for Disease Control and Prevention (CDC), the California Department of Public Health (CDPH), the California Conference of Local Health Officers and the California Tuberculosis Controllers Association (CTCA).
What specifically did AB 1667 change on January 1, 2015?
Replaces the mandated TB examination on initial employment with a TB risk assessment, and TB testing based on the results of the TB risk assessment, for the following groups:
Persons initially employed by a school district, or employed under contract, in a certificated or classified position (California Education Code, Section 49406)
Persons initially employed, or employed under contract, by a private or parochial elementary or secondary school or any nursery school (California Health and Safety Code, Sections 121525 and 121555)
Persons providing for the transportation of pupils under authorized contract (California Health and Safety Code, Section 121525)

Replaces the mandated TB examination at least once each four years of school employees who have no identified TB risk factors or who test negative for TB infection with a TB risk assessment, and TB testing based on the TB risk assessment responses. (California Education Code, Section 49406 and California Health and Safety Code, Section 121525)
Replaces mandated TB examination (within the last four years) of volunteers with “frequent or prolonged contact with pupils” in private or parochial elementary or secondary schools, or nursery schools (California Health and Safety Code, Section 121545) with a TB risk assessment administered on initial volunteer assignment, and TB testing based on the results of the TB risk assessment.

For school district volunteers with “frequent or prolonged contact with pupils,” mandates a TB risk assessment administered on initial volunteer assignment and TB testing based on the results of the TB risk assessment. (California Education Code, Section 49406)

What specifically did SB 792 change on September 1, 2016?
California Health and Safety Code, Section 1597.055 requires that persons hired as a teacher in a child care center must provide evidence of a current certificate that indicates freedom from infectious TB as set forth in California Health Safety Code, Section 121525.
What specifically does SB 1038 change on January 1, 2017?
California Education Code, Section 87408.6 requires persons employed by a community college in an academic or classified position to submit to a TB risk assessment developed by CDPH and CTCA and, if risk factors are present, an examination to determine that he or she is free of infectious TB; initially upon hire and every four years thereafter.

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Who developed the school staff and volunteer TB risk assessment?
The California Department of Public Health (CDPH) and the California Tuberculosis Controllers Association (CTCA) jointly developed the TB risk assessment. The risk assessment was adapted from a form developed by Minnesota Department of Health TB Prevention and Control Program and the Centers for Disease Control and Prevention.

Who may administer the TB risk assessment?
Per California Education and Health and Safety Codes, the TB risk assessment is to be administered by a health care provider. The risk assessment should be administered face-to-face. However, given the COVID-19 emergency response, the TB risk assessment may also be administered via telehealth. The practice of allowing employees or volunteers to self-assess is discouraged.

What is a “health care provider”?
A “health care provider” means any organization, facility, institution or person licensed, certified or otherwise authorized or permitted by state law to deliver or furnish health services.

If someone is a new employee and has a TB test that was negative, would he/she need to also complete a TB risk assessment?
Check with your employer about what is needed at the time of hire.

If someone transfers from one K-12 school or school district to another school or school district, would he/she need to also complete a TB risk assessment?
Not if that person can produce a certificate that shows he or she was found to be free of infectious tuberculosis within 60 days of initial hire, or the school previously employing the person verifies that the person has a certificate on file showing that the person is free from infectious tuberculosis.

If someone does not want to submit to a TB risk assessment, can he/she get a TB test instead? Yes, a TB test, and an examination if necessary, may be completed instead of submitting to a TB risk assessment.

If someone has a positive TB test, can he/she start working before the chest x-ray is completed? No, the x-ray must be completed and the person determined to be free of infectious TB prior to starting work.
If someone has a positive TB test, does he/she need to submit to a chest x-ray every four (4) years? No, once a person has a documented positive TB test followed by an x-ray, repeat x-rays are no longer required every four years. If an employee or volunteer becomes symptomatic for TB, then he/she should promptly seek care from his/her health care provider.

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What screening is required for someone who has a history of a positive TB test or TB disease at hire?
If there is a documented history of positive TB test 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.

For volunteers, what constitutes “frequent or prolonged contact with pupils”?
Examples of what may be considered “frequent or prolonged contact with pupils” include, but are not limited to, regularly-scheduled classroom volunteering and field trips where cumulative face-to-face time with students exceeds 8 hours.

Who may sign the Certificate of Completion?
If the patient has no TB risk factors then the health care provider completing the TB risk assessment may sign the Certificate of Completion.
If a TB test is performed and the result is negative, then the licensed health care provider interpreting the TB test may sign the Certificate.
If a TB test is positive and an examination is performed, only a physician, physician assistant, or nurse practitioner may sign the Certificate.

What does “determined to be free of infectious tuberculosis” mean on the Certificate of Completion? “Determined to be free of infectious TB” means that a physician, physician assistant, or nurse practitioner has completed the TB examination and provided any necessary treatment so that the person is not contagious and cannot pass the TB bacteria to others. The TB examination for active TB disease includes a chest x-ray, symptom assessment, and if indicated, sputum collection for acid-fast bacilli (AFB) smears cultures and nucleic acid amplification testing.

What if I have TB screening or treatment questions?
Consult the federal Centers for Disease Control and Prevention’s Latent Tuberculosis Infection: A Guide for Primary Health Care Providers (2013) (http://www.cdc.gov/tb/publications/LTBI/default.htm). If you have specific TB screening or treatment questions, please contact your local TB control program (http://www.ctca.org/locations.html).

Who may I contact to get further information or to download the TB risk assessment?
California Tuberculosis Controllers’ Association
https://www.ctca.org/providers/
California Department of Public Health, Tuberculosis Control Branch: (510) 620-3000 https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/TBCB.aspx
California School Nurses Organization: (916) 448-5752 or email csno@csno.org http://www.csno.org/
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