ANNUAL TUBERCULOSIS QUESTIONNAIRE Anuual Tuberculosis Questionnaire "*" indicates required fields Employee Name:* First For personnel who have a known positive PPD and previously negative chest x-ray, you are requested to complete this questionnaire with either a yes or no.HAVE YOU NOTICED ANY OF THE FOLLOWING? Unexplained Fevers Yes No Night Sweats Yes No Unintentional weight loss Yes No Cough Yes No Hoarseness Yes No Bloody Sputum Yes No Have you completed INH therapy? Yes No Have you ever had a BCG vaccine? Yes No Have you had an x-ray while employed here? Yes No Employee Signature Date MM slash DD slash YYYY Have you had an x-ray while employed here? Yes No Comments:Agency Representative: Date MM slash DD slash YYYY {{#message}}{{{message}}}{{/message}}{{^message}}Your submission failed. The server responded with {{status_text}} (code {{status_code}}). Please contact the developer of this form processor to improve this message. Learn More{{/message}}{{#message}}{{{message}}}{{/message}}{{^message}}It appears your submission was successful. Even though the server responded OK, it is possible the submission was not processed. Please contact the developer of this form processor to improve this message. Learn More{{/message}}Submitting…