CDPH's Tuberculosis Control Branch publishes this pediatric TB risk assessment with a user guide to identify asymptomatic children who should be tested for latent TB infection. The provider checks three risk boxes, or None, and records the patient, provider and assessment date. Some school districts and child care programs that require TB screening at entry accept the completed form.
The child's 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 family completes nothing.
Download the current version from the source each time; forms change without notice.
California Pediatric Tuberculosis Risk Assessment and User Guide
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Not statewide. Some California school districts and child care programs require TB screening at entry and accept this CDPH form as documentation. The provider completes the assessment, keeps it in the chart, and gives the family a copy when the school or program asks for one.
The user guide says to complete it for new patients, for children with possible new TB exposure since the last assessment, and during routine well-child visits. Repeat testing is only for children who previously tested negative and have a new risk factor, unless they were younger than 3 months when first tested.
Yes. CDPH publishes a separate Adult TB Risk Assessment and User Guide for people over 18, which adds a box for homelessness or incarceration. Pre-K, K-12 and community college staff and volunteers use CDPH's School Employee questionnaire and Certificate of Completion instead.