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Run: Staff Tuberculosis Screening and Clearance Tracking Log

Track staff and volunteer TB screening, test results, clearance status, and follow-up actions in one log. Use it to document childcare and school employment ...

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Staff or Volunteer Identification

Full Name (required)

Role Type (required)

Department or Program

Optional. Use only if needed for internal assignment or audit trail.

Worksite or School Location

TB Screening Basis

Screening Basis (required)

Screening Date (required)

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.

Yes No N/A

Risk Assessment or Test Result

Risk Assessment Result

Test Type

Test Result

Test Result Date

Follow-Up Needed

Clearance and Follow-Up

Clearance Status (required)

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 (required)

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.

Yes No N/A

PII Notice Acknowledged (required)

I understand this form collects personally identifiable information and limited health-related information necessary for compliance.

Yes No N/A

Submitted By

Auto-filled for audit trail if available.

Submission Date

Auto-filled for audit trail if available.

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Email (required)

Your name (optional)

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