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NC Child Care Tuberculosis Screening Form

North Carolina requires everyone providing child care in centers and family child care homes to be screened for tuberculosis by a licensed health care professional before coming into contact with children. Page one holds the risk and symptom questionnaires; page two records a tuberculin skin test or IGRA, which is done only when a screening answer is yes.

Who completes it

The individual answers the questionnaires and signs the health statement. A licensed health care professional administers the screening and signs with printed name and location, and an authorized health professional signs any test record on page two.

Submitting and payment

How to submit it
The completed form is kept in the operator's or staff member's medical file, separate from the personnel file kept on site.
Who pays
The form does not set a fee; it notes both screening and testing are available at the local health department.

Good to know

  • Directors, operators, additional caregivers, substitutes and anyone volunteering more than once a week must be screened.
  • The form tells clinicians a negative risk and symptom screen counts as a negative TB test, and an IGRA is preferred over a skin test for otherwise low-risk people who screen positive.
  • The five risk questions cover birth in, or more than a month living in, Africa, Asia, Central or South America or Eastern Europe, immune compromise, specific exposures and settings, and known contact.
  • The rules are 10A NCAC 09 .0701(a) for centers and .1702(b)(4) and .1729 for family homes; a Spanish version is available.

Get the official form

Download the current version from the source each time; forms change without notice.

Tuberculosis Screening Form

Official pagePDFVersión en español

Fill it with Vero

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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How this list is checked

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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Frequently asked questions

Does every North Carolina child care worker need a TB test?

No. Everyone must be screened, but the form says testing should only be performed if the person answers yes to a screening question. A negative risk and symptom screen is considered a negative tuberculosis test, and no further testing is required.

Which TB test does North Carolina prefer for child care staff?

For otherwise low-risk individuals who answer yes on the risk or symptom questionnaire, the form says an interferon gamma release assay is preferred over a tuberculin skin test. Page two records either test with dates and results.

Is the North Carolina TB screening form available in Spanish?

Yes. The Division of Child Development and Early Education posts a Spanish version of the Tuberculosis Screening or Test Form next to the English version on its provider documents and forms page.