Staff Tuberculosis Screening and Clearance Tracking Log

Tracks staff and volunteer tuberculosis risk assessments, test results, clearance status, and follow-up actions for childcare and school employment.

Staff or Volunteer Identification

• Full Name
• Role Type
• Department or Program
  Optional. Use only if needed for internal assignment or audit trail.
• Worksite or School Location

TB Screening Basis

• Screening Basis
• Screening Date
• Provider or Clinic Name
  Optional unless your policy requires provider documentation.
• Documentation Received
  Check if written documentation was provided for the screening or test result.

Risk Assessment or Test Result

• Risk Assessment Result
• Test Type
• Test Result
• Test Result Date
• Follow-Up Needed

Clearance and Follow-Up

• Clearance Status
• Clearance Date
• Restrictions or Notes
  Include only necessary work restrictions or administrative notes. Avoid unnecessary clinical detail.
• Next Review Date
  Use for annual re-screening or follow-up scheduling.

Consent, Disclosure, and Audit Trail

• Consent and Disclosure Acknowledgment
  I acknowledge that TB screening information is being collected for employment or volunteer clearance purposes and will be handled according to applicable privacy and health-information policies.
• PII Notice Acknowledged
  I understand this form collects personally identifiable information and limited health-related information necessary for compliance.
• Submitted By
  Auto-filled for audit trail if available.
• Submission Date
  Auto-filled for audit trail if available.