Form PC-262-12 Reactive Tuberculin Test Evaluation Form

Peace Corps – Reactive Tuberculosis Screening Test Evaluation Form | PC-262-12 [Rev. Aug 2020]

REACTIVE TUBERCULOSIS SCREENING TEST EVALUATION FORM

Dear Medical Provider,

Your patient has applied to serve with the Peace Corps and has a history of a reactive screening test to tuberculosis. Peace Corps needs additional information about this person’s risk for developing active tuberculosis. Please provide the information requested below.

I. CURRENT TB TEST

Tuberculin skin test or IGRA blood tests are accepted. IGRA is preferred in persons with a history of prior BCG administration. Test must have been completed within the past six months. No current testing is required for people with previous documented positive skin testing or positive IGRA testing. Instead, complete symptom survey (Section V) and consider chest x-ray.

Select one

Tuberculin skin test

Date: mm of induration:

Interferon Gamma Releasing Assay (QuantiFERON^®-TB Gold/T. Spot Blood Test)

Date: ______________ Result: Positive Negative

PRIVACY ACT NOTICE

Authority: This information is collected under the authority of the Peace Corps Act, 22 U.S.C. 2501 et seq.

Purpose: It will be used primarily for the purpose of determining your eligibility for Peace Corps service and, if you are invited to service as a Peace Corps Volunteer, for the purpose of providing you with medical care during your Peace Corps service.

Routine Uses: This information may be used for the routine uses described in the Privacy Act, 5 U.S.C. 552a(b), and the Peace Corps' Routine Uses A through N, as listed on the Peace Corps’ Privacy Program webpage, and listed in System of Records PC-17, “Volunteer Applicant and Service Records System.” Among other uses, this information may be used by those Peace Corps staff members who have a need for such information in the performance of their duties. It may also be disclosed to the Office of Workers’ Compensation Programs in the Department of Labor in connection with claims under the Federal Employees’ Compensation Act and, when necessary, to a physician, psychiatrist, clinical psychologist, licensed clinical social worker or other medical personnel treating you or involved in your treatment or care.

Applicable SORN: System of Records PC-17, Volunteer Applicant and Service Records System.

Disclosure: Your disclosure of this information is voluntary; however, your failure to provide this information or failure to disclose relevant information may result in the rejection of your application to become a Peace Corps Volunteer.

BURDEN STATEMENT

Public reporting burden for this collection of information is estimated to average an hour and 45 minutes per applicant and 30 minutes per physician per response. This estimate includes the time for reviewing instructions and completing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: FOIA/Privacy Officer, Peace Corps, 1275 First Street, NE, Washington, DC, 20526 ATTN: PRA (0420-0550). Do not return the complete form to this address.

2. TB TEST HISTORY:

No prior TB test

Prior TB test(s)

Date: mm of induration:

Date: mm of induration:

Date: mm of induration:

IGRA blood test

Date_______________ Result__________

BCG vaccine (If reported by applicant, please provide)

Date of vaccination:

2. TREATMENT HISTORY:

Treatment should be completed or initiated before an applicant can be medically cleared. If treatment is not initiated, there must be a strong medical contraindication.

No treatment received:

Contraindication: __________________________________

Treatment:

Drug regimen_______________

Date treatment initiated________________

Date treatment completed____________________

*Attach copy of baseline liver functions tests for people currently being treated for latent tuberculosis infection (LTBI).

2. RISK ASSESSMENT FOR DEVELOPING ACTIVE TB

YES NO

Person infected with the human immunodeficiency virus.

Close contact (i.e., those sharing the same household or other enclosed environments of person(s) known or suspected to have tuberculosis). Foreign-born person who has recently arrived (within five years) from a country that has a high incidence or prevalence of tuberculosis (includes most countries in Asia, Africa, and Latin America).

Resident or employee of high-risk congregate setting (e.g., correctional institution nursing home, mental institution, or shelter for the homeless).

Person who injects illicit drugs or uses other high-risk substances (e.g., crack cocaine).

Health care worker who is exposed to high-risk clients or is working/has worked in a mycobacteriology laboratory.

V. CURRENT TB SYMPTOMS

YES NO

Cough lasting longer than three weeks

Night sweats (drenching bed clothes that last more than one week)

Unexplained weight loss of 10 pounds or more than 10 percent of normal weight

Fatigue/malaise lasting longer than two weeks

Loss of appetite > two weeks

Fever > 100 degrees lasting > one week

6. CURRENT CHEST X-RAY DOCUMENTATION REQUIRED FOR:

1. Anyone with a reported induration or interval change in induration ≥ 10mm.

2. Anyone with a history of a positive TB screening test (PPD or IGRA) who did not complete a full course of latent TB treatment.

3. Anyone with a history of a positive TB screening test (PPD or IGRA) with symptoms suspicious for TB, regardless of latent TB treatment.

4. Anyone with a history of latent TB treatment who has not had a CXR within the previous 12 months.

6. RECOMMENDATIONS FOR FURTHER EVALUATION AND TREATMENT

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

VIII. CLOSING SIGNATURE

Physician Name Physician Signature Date

Peace Corps – Reactive Tuberculosis Screening Test Evaluation Form | PC-262-12 [Rev. Aug 2020] Page 5 of 5