Massachusetts DPH recommends that school-aged children in public or private schools have this risk assessment completed and documented on the school health form. The one-page tool identifies asymptomatic children and adolescents to test for latent TB infection: testing is recommended if any of three risk boxes is checked, and children with no risk factors should not be tested.
A primary care provider, pediatric clinic, school nurse or local public health nurse completes it, checking any risk boxes or the no-risk box and entering the provider, assessment date, patient name and date of birth.
Download the current version from the source each time; forms change without notice.
Massachusetts Pediatric Tuberculosis Risk Assessment
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.
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DPH recommends a risk assessment, not universal testing, for school-aged children in public and private schools. Testing is recommended only when a risk box is checked; children with no risk factors should not be tested, because low-risk testing produces false positives. The assessment does not supersede any locally mandated testing.
DPH's user guide says to complete it for new patients, for children with possible new TB exposure since the last assessment, and at routine well-child visits. Retesting is only for children who previously tested negative and have new risk factors, such as new close contact, new immunosuppression or foreign travel.
The child gets a TB symptom screen and a referral for medical evaluation, including a history, physical exam and two-view chest X-ray. Once active disease is ruled out, treatment of latent TB infection is recommended, with shorter rifampin or isoniazid-rifapentine regimens preferred in most children. Positive results are reported to DPH.