Form G is Hawaii's department-approved TB risk assessment for adults and children under HAR 11-164.2. It asks about country of birth, time spent in countries with high TB case rates, contact with infectious TB, immune-suppressing conditions or planned treatments, and household members or visitors from abroad, with separate wording for initial and annual follow-up evaluations.
Medical staff (RN, LPN, MD, DO, APRN, NP or PA) review the answers and sign. The patient answers the questions, or another person provides the information and is named with their relationship.
Download the current version from the source each time; forms change without notice.
TB Risk Assessment for Adults and Children (TB Document G)
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For school, child care and post-secondary students and staff, and for food handlers, the DOH TB Clearance Manual starts with Form G and the Form H symptom screen. If neither is positive, the provider can issue a clearance without testing. Health care facility workers also complete Forms G and H at annual follow-up.
Yes. The manual lets an RN or LPN perform the risk assessment and symptom screen and measure TSTs, and the form's reviewer line lists RN, LPN, MD, DO, APRN, NP and PA. Only a licensed MD, DO, APRN, NP or PA can interpret the results and issue the clearance on Form F.