Prince George’s Community College
Tuberculosis Symptoms Checklist
(Please Print Clearly)
Name
Address
Home Telephone #
Work Telephone #
PGCC Program
Student ID #
Date of Birth
Sex
City, State, Zip Code
Circle One: Student Staff Faculty/Admin Other
Date of PPD positive status
Date of last chest x-ray
Result of last chest x-ray
Persons with a productive cough lasting more than three weeks with the presence of one other
symptom listed below (2 a-d) shall be considered a TB suspect.
1.
2.
Yes
a.
b.
c.
d.
No
Productive cough for
Blood in sputum
Fever
Night Sweats
Unexplained weight loss
Physician/Health Care Provider Signature
weeks/months (circle one)
Date
Cleared
Referred
From: Prince George’s County Health Department Tuberculosis Control Program
Groups at high-risk for TB:
• Persons with HIV infection or risk factors for HIV but unknown HIV status
• Close contacts of a person with infectious TB
• Person with certain medical conditions
• Persons who inject drugs
• Foreign-born persons from area of the world where TB is common (e.g., Asia, Africa, and Latin
America)
• Medically underserved, low income populations, including high-risk racial and ethical groups
• Residents of long-term care facilities (e.g., correctional facilities and nursing homes)
• Other groups identified locally as having an increased prevalence of TB (e.g., migrant
farmworkers or homeless persons)
Revised 7/20