Tuberculosis (TB) Questionnaire

As healthcare workers you will be offered vaccination for infections that you may be exposed to occupationally. Laboratory workers and healthcare staff in regular contact with patients are at risk of contracting tuberculosis (TB). All healthcare staff who may have contact with patients or potentially infectious specimens should be screened and offered a BCG vaccination, if necessary, in accordance with NICE Guidance Tuberculosis 2023.

To identify if a BCG vaccination is required please complete the online TB Questionnaire by answering each of the following questions. For those who have previously received a BCG vaccination, the questionnaire will also identify if TB screening by a blood test is required. All fields marked * are required fields and must be completed. On submission a PDF summary of your completed form shall be emailed to GO Health Services and a copy sent to your own email address.

It is important to provide evidence of a previous BCG vaccination or TB screening tests. Please send evidence to gram.ohs@nhs.scot.

This questionnaire will be held in confidence by GO Health Services and will form part of your Occupational Health record. For full details of how your personal information is used please see our GDPR Statement.

This form is also available in other formats and languages, upon request. Please call NHS Grampian Corporate Communications on (01224) 551116 or (01224) 552245 for further information.

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SECTION 1: PERSONAL DETAILS

Which organisation do you work/study with? *

• NHS Grampian
• University of Aberdeen
• Robert Gordon University

Forename *

Surname *

Date of Birth *

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Country of Birth * United KingdomAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua & DepsArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia HerzegovinaBotswanaBrazilBruneiBulgariaBurkinaBurundiCambodiaCameroonCanadaCape VerdeCentral African RepChadChileChinaColombiaComorosCongoCongo {Democratic Rep}Costa RicaCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIreland {Republic}IsraelItalyIvory CoastJamaicaJapanJordanKazakhstanKenyaKiribatiKorea NorthKorea SouthKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmar, {Burma}NamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussian FederationRwandaSt Kitts & NevisSt LuciaSaint Vincent & the GrenadinesSamoaSan MarinoSao Tome & PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth SudanSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad & TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe

Mobile Phone Number *

Email Address *

Email

Confirm Email

Address *

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SECTION 2: TB QUESTIONNAIRE

Have you ever lived, worked or travelled outside the UK for 3 months or longer? * YesNo

Please provide further information: which countries and dates of travel: *

Have you ever been treated for TB in the past? * YesNo

What type of TB were you treated for? * LatentActiveUnknown

Please send in evidence of the treatment received

Have you had any of the following in the past year? *

• Coughing up blood or long term productive cough
• Unexplained weight loss
• Unexplained fever, night sweats, or high temperature
• None of the above

Have you previously had a Mantoux or IGRA test? * YesNo

Please provide date: *

Please send in evidence of test

Have you had a severe allergic reaction to a Mantoux test in the past? * YesNo

Please provide further information: *

Have you previously been vaccinated against TB (BCG vaccination)? * YesNo

Please send in vaccination evidence

Do you have a visible BCG scar? * YesNo

Are you or might you be pregnant? * YesNo

Are you or might you be HIV positive? * YesNo

Please provide further information: *

Do you have any allergies? * YesNo

Please provide further information: *

Do you have diagnosed medical condition? * YesNo

Please provide further information: *

Are you taking regular prescribed medication (in the last 12 months)? * YesNo

Please provide further information including name, dosage and duration of use: *

Have you had an MMR or Covid vaccine in the last 4 weeks? * YesNo

Please state date of vaccination: *

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