| 1.Was your country of birth the US? | | | |
| If not U.S., what was year of entry to U.S. | |
| 2.Have you had the BCG vaccine (Bacillus Calmete–Guérin vaccine) | | | |
| 3.Have you traveled outside the U.S. during the past 2 years? | | | |
| If yes, to where and for how long? | |
| 4.Have you ever spent time with a person who had Tuberculosis disease? | | | |
5.Have you ever been told you have tuberculosis?
| | | |
| 6.Have you taken medication for tuberculosis (latent or active disease)? | | | |
| If yes, what and for how long? | |
| 7.Have you had a skin test or blood test for tuberculosis? | | | |
| If yes, when: | |
| 8.Have you had a mark on your arm 2-3 days after a TST? | | | |
| 9.Have you been sent for a chest x-ray after a TST or IGRA | | | |
| 10.Usual doctor or place for care when you are sick? | |
| 11.Are you pregnant? | | | |
| If my insurance does not cover the vaccine or administration fee, I understand I am responsible for all co-pays, deductibles, and uncovered/exhausted benefits. |