DS-6573 TB Risk Assessment

OMB APPROVAL NO 1405-XXXX
EXPIRATION DATE: XX-XX-20XX
ESTIMATED BURDEN: XX MINUTES

U.S. Department of State

Bureau of Medical Services

TUBERCULOSIS (TB) RISK ASSESSMENT FOR
LOCALLY EMPLOYED STAFF (LES)
Section I: Demographic and Employment Information - To be completed by the candidate/employee
Name (Last, First, MI)

Date of Birth (mm-dd-yyyy)

Type of Evaluation (Note: Periodic Risk Assessment should focus on change in risk from previous assessment)

Date (mm-dd-yyyy)

Initial

Periodic (Drivers Only)

Job Title/Section

Office/Location

Country of Residence

Country of Birth

Previous Anti-Tuberculosis ("BCG") Vaccine?

If yes, approximately when last received (mm-yyyy)

Yes

No

Section II: TB Risk Factors - To be completed by the candidate/employee
If yes, for how long and which symptoms?

Yes

No

Do you have cough, fever, night sweats, loss of appetite,
weight loss, or fatigue?

Yes

No

Have you ever had a positive tuberculosis (TB) skin test or
blood test for TB?

If yes, When (mm-dd-yyyy)?

If yes, What type of test?

Yes

No

Have you ever been told you had or have latent
tuberculosis Infection (LTBI)?

If yes, When (mm-dd-yyyy)?

Treated?

Yes

No

Have you ever been told you had or have TB disease, or
have you ever been treated for active TB?

If yes, When (mm-dd-yyyy)?

Yes

No

Have you ever been told you had or have an abnormal
chest x-ray?

If yes, When (mm-dd-yyyy)?

If yes, what country/countries?

Yes

No

Have you lived in or traveled in a country identified by the
WHO with increased TB risk (greater than 50 per 100,000
incidence*) for more than one month in the last three
years?

Yes

No

In the last year, have you lived with, or spent time with someone with active TB?

Yes

No

In the last year, have you closely interacted (more than 6
hours of face-to-face interaction at less than 6 feet (~2
meters) of distance) with high-risk populations (homeless,
imprisoned, IV drug users, refugees, etc.)?

No

Do you have an immunocompromising condition, such as:
• Diabetes
• Chronic kidney failure
• Cancer of the neck, head, lungs, blood, or lymph system
• HIV/AIDS; or other condition affecting your immune system (including organ transplantation)

Yes

Yes

No

Treated?
Yes

No

If yes, When (mm-dd-yyyy)?

Additional Comments?

DS-6573
03-2024

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Name of Examinee

DOB

Section III: Provider/Clinician Assessment of TB Risk
RISK ASSESSMENT - Check boxes as appropriate

Increased Risk (answering "yes" to
one or more responses in Section II
above)
Baseline chest x-ray required for new
employees based on risk assessment
(costs of the initial chest x-ray and
IGRA or TST if indicated are covered
as part of the pre-employment
process)

CHEST X-RAY POSITIVE - Candidate/employee should seek follow-up care as indicated. Such
care may include completion of TB risk assessment with Interferon-Gamma Release Assay
(IGRA) (preferred), or Tuberculin Skin Test (TST) performed through the contracted local provider
or the local health system. To continue candidacy or employment, candidate/employee is
responsible for obtaining documentation certifying NO ACTIVE TB including completion of
appropriate treatment. Costs for diagnostic tests beyond CXR and IGRA/TST, as well as
treatment, are the responsibility of the candidate/employee.
CHEST X-RAY NEGATIVE - Candidate/employee permitted to continue candidacy/employment.
Candidate/employee may choose to undergo IGRA or TST through the contracted local provider.
If they choose to undergo further testing and it is available, cost for IGRA and TST testing may be
covered by the Mission as a courtesy. Any subsequent testing, costs, or treatments are the
responsibility of the candidate/employee. A positive IGRA or TST in the absence of chest x-ray
findings suggests latent tuberculosis infection (LTBI). Those with LTBI may continue their
candidacy/employment and are encouraged to seek care per local public health
recommendations. Treatment for LTBI is not required for candidacy/employment.

Low risk (answering "no" to all responses in Section II above). Baseline chest x-ray/IGRA/TST not required.
Note: For driver/vehicle operators, the TB Risk Assessment Questionnaire should be repeated at the time of their periodic driver evaluation. Based on
the Risk Assessment, actions should be taken as indicated above.

CHECK ONE OF THE FOLLOWING
The above employee has no evidence of active TB based on the risk
assessment or testing above.
Provider/Clinician Name

Further evaluation or testing required due to:

Provider/Clinician Signature

Date (mm-dd-yyyy)

Countries with TB incidence greater than 50/100,000 are considered increased risk. For the most recent data on TB incidence, refer to the World Health
Organization:
https://www.who.int/data/gho/data/indicators/indicator-details/gho/incidence-of-tuberculosis-(per-100-000-population-per-year)
Paperwork Reduction Act Statement
Releases or disclosures of confidential medical information are governed by the Privacy Act of 1974, as amended, 5 U.S.C. § 552a et seq., and the
Rehabilitation Act of 1973, as amended, 29 U.S.C. § 701 et seq.
Privacy Act Statement
AUTHORITIES: The information is sought pursuant to the Foreign Service Act of 1980, as amended (Title 22 U.S.C. 4084, 3901, and 3984) and the
Public Health Service Act of 1944, as amended (Title 42 U.S.C 247b-6).
PURPOSE: The information requested on this form is intended to prevent the introduction, transmission or spread of tuberculosis.
ROUTINE USES: Unless otherwise protected by law, the information solicited on this form may be made available to appropriate agencies, whether
Federal, state, local, or foreign, for law enforcement and other authorized purposes. The information may also be disclosed pursuant to court order.
The information may also be made available to local Health Units. More information on the Routine Uses for the system can be found in the System of
Records Notice State-24, Medical Records.
DISCLOSURE: Providing this information is voluntary; however, failure to provide this information may result in disqualification of employment.
The Genetic Information Nondiscrimination Act of 2008 (GINA)
To the individual and/or health care provider completing the medical history review /exam: The Genetic Information Nondiscrimination Act of 2008
(GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family
member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you NOT provide any genetic
information when responding to this request for medical information. 'Genetic Information' as defined by GINA, includes an individual's family medical
history, the results of an individual's or family members' genetic tests, the fact that an individual or an individual's family member sought or received
genetic services, and genetic information of a fetus carried by an individual or an individual's family member or an embryo lawfully held by an individual
or family member receiving assistive reproductive services.
DS-6573

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