CDPH's Tuberculosis Control Branch publishes this adult (over 18) TB risk assessment with a user guide to identify asymptomatic adults in primary care who should be tested for latent TB infection. The provider checks four risk boxes, or None, and records the patient, provider and assessment date. Employers, colleges and programs may ask the patient for a copy as TB screening documentation.
The health care provider completes the one-page assessment: patient name and date of birth, the risk factor boxes or None, and the provider's name and assessment date. The patient completes nothing.
Download the current version from the source each time; forms change without notice.
California Adult Tuberculosis Risk Assessment and User Guide
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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It depends on the employer. The assessment is designed for primary care, and its guide says it does not replace testing mandated by statute, regulation or policy for groups such as health care workers and correctional or long-term care employees. School and community college staff use CDPH's separate School Employee questionnaire and Certificate of Completion.
CDPH lists a College and University Students risk assessment dated September 2026, but its link on the TB Risk Assessment page currently opens the adult risk assessment PDF. The adult user guide also points to the American College Health Association's TB screening guidelines for college and university students.
The user guide says to administer it at least once and to screen for new risk factors at later preventive visits. Retesting is only for people who previously tested negative and have a new risk factor, such as new close contact with infectious TB, new immunosuppression, or extended travel or residence abroad.