Tuberculosis Risk Assessment Form for STUDENTS
Instructions:
• All students must be assessed for their risk of tuberculosis (TB) before commencing a clinical placement.
• Please complete the following questions and return the completed form and any additional documentation (if required) to
your Education Provider Placement Coordinator prior to commencement of placement.
• Retain a copy of this form and any relevant documentation to take with you if any further assessment is required.
• If you do not understand the questions please complete this form with your doctor’s help.
• Further testing and/or health assessment may be required, depending on your personal circumstances.
Privacy Notice: Personal information about students collected by Queensland Health is handled in accordance with the Information Privacy Act 2009. Queensland Health is
collecting your personal information to meet its obligations to protect the public and to provide a safe workplace as per the current Tuberculosis Control QH-Health Service Directive
2018 and the Public Health Act 2005 and Public Health Regulation 2018. All personal information will be securely stored and reasonable steps will be taken to keep it accurate,
complete and up-to-date. Personal information recorded on this form will not be disclosed to Queensland Health officers or third parties unless the disclosure is authorised or
required by or under law. If you choose not to provide your personal information, you will not meet the condition of placement. For further information about how Queensland Health
protects your personal information, or to learn about your right to access your own personal information, please see our website at www.health.qld.gov.au.
Part A: Signs of active TB - Do you currently have any of the following symptoms?
1. Cough for more than 2 weeks (not related to an existing diagnosis or condition)
No Yes
2. Unexplained fever for more than 1 week
No
Yes
3. Recent unexplained weight loss
No
Yes
4. Coughing up blood
No
Yes
5. Excessive sweating during the night for more than 1 week
No
Yes
If you have answered YES to any questions from Part A:
Make an urgent appointment with your doctor or TB Control Unit for assessment of your symptom/s. Further referral
to a TB specialist may be recommended by your doctor.
You will require a clearance for signs of active TB from the assessing clinician (doctor or TB Control Unit) to be
provided to your Education Provider Placement Coordinator before you can commence a placement:
Clearance for active TB required No Yes Clearance for active TB attached Yes
Please continue over page
Student Information
Given name/s:
Student Number:
Education Provider:
Course/Module of Study:
Email:
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Part C: Previous TB risk assessment procedures: – In the time since encountering the risk factors in Part B have
you undergone any assessments or screening as below. If you have previously had a test for latent TB, to avoid
unnecessary repetition of testing please take (if available) any supporting documents and additional information as
indicated below to your doctor or TB Control Unit.
Previous employment or immigration screening for TB? No Yes
Previous TB risk assessment is on SPA (Staff Protect Application-Queensland Health Data Base)
No
Yes
Previous pathology result (Quantiferon test or T-spot test) No Yes
Previous printed result of a tuberculin skin test result (also called Mantoux test) No Yes
Part B: TB exposure risk history
1. Were you born in Australia?
No Yes
If no, in what country were you born?
2. Other than Australia or your country of birth, have you spent three (3) months or more in total within the past
five (5) years visiting or living in any other country/ies? (For example, two months in country A and one month
in country B is three months in total).
No Yes
If yes, which countries?
Check the TB country incidence list (www.health.nsw.gov.au/Infectious/tuberculosis/Pages/high-incidence-countries.aspx) for
each country you have listed in questions 1 and 2 and complete the following questions:
3. Were you born, and/or have you spent three (3) months or more in total within the past five (5) years visiting
or living in country/ies with a TB burden greater than 40 cases per 100 000 population (see link above)?
No Yes
4. Have you been in direct contact with a person with active TB disease, without using appropriate infection
control precautions, within the past 2 years and you were not assessed for exposure to TB by hospital or
public health authorities (Contact may be work or non-work related).
No Yes
5. Have you previously worked (> 3 months) in any of the following settings: respiratory units; infectious disease
units or other medical units caring for infectious TB patients; clinical procedure units conducting bronchoscopy
and/or sputum induction; TB laboratories; mortuaries?
No Yes
6. Have you ever been diagnosed with active TB (i.e. not latent TB)?
No
Yes
If yes, in what year did you complete
treatment?
7. Do you have any underlying health issues or take any medications which may cause immunosuppression ?
No
Yes
If you have answered YES to any of questions 3 – 5 from Part B, you require a test for latent TB infection:
an Interferon Gamma Release Assay (IGRA) blood test can be ordered by your doctor – pathology fees may apply (a positive
or indeterminate IGRA result requires further consultation at a TB Control Unit or with your doctor. Your doctor may refer you to
a TB specialist.
OR
a Tuberculin Skin Test (TST/Mantoux test) can be performed by referral to a TB Control Unit – at no cost to the patient, but
requires a follow-up appointment 2 or 3 days later.
If testing for latent TB infection is required (and you have answered NO to all questions in Part A), you will still be able to commence
placement. However, you must undertake further assessment with a doctor or at a TB Control Unit.
If you have answered YES to any of questions 6 – 7 from Part B, you require further assessment. Contact your TB Control Unit for
advice.
NOTE there is no out-of-pocket expense for treatment of TB in public health facilities in Queensland
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Assessment Summary: Please tick the appropriate TB Risk Assessment Outcomes.
If YES to any questions in Part A clearance for active TB is
required prior to placement .
Clearance for active TB attached to Risk Assessment form and
returned to your Education Provider Placement Coordinator .
If NO to all questions in Part A AND NO to Part B questions 3
to 7 (inclusive)-Nil further assessment required .
Completed and signed Risk Assessment form returned to your
Education Provider Placement Coordinator .
If YES to any of questions Part B questions 3 – 7 further
testing/consultation with a doctor or consultation at a TB
Control Unit is required
.
Completed and signed Risk Assessment form returned to your
Education Provider Placement Coordinator .
Student consents to undertake assessment with a doctor or at a TB
Control Unit .
TB Control Units Contact Details www.health.qld.gov.au/clinical-practice/guidelines-procedures/diseases-
infection/diseases/tuberculosis
Acknowledgement and Consent:
I certify that I have read and understand the Queensland Health: Protocol for the control of tuberculosis— section 3.3.18
Workers and students in health care facilities risk assessment on the Queensland Health Clinical Placement website, in
preparation for my placement. I agree to comply with the guidelines and all procedures in place at the Queensland
Hospital and Health Service facility at which I am placed, in respect of Queensland Health vaccination and
infection control of health care workers.
I understand that this risk assessment and any required follow-up action is one of the requirements of eligibility
for a placement at a Queensland Hospital and Health Service facility, and I agree to take action as required.
I consent to my education provider giving personal information in this form to Queensland Health (including the
Department of Health and Hospital and Health Services) for placement and infection management planning and
response. This may include infection control units and TB control units.
I certify that the information I have provided in this risk assessment is true and correct.
Full Name:
Signed: Date:
Further information and Resources
- Tuberculosis Risk Assessment- Frequently Asked Questions (FAQ) for Workers in Queensland Health Facilities
- Tuberculosis Risk Assessment-Guideline for Education Provider Placement Co-ordinators
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Clinician Use Only
Assessment of Tertiary Students for active and latent tuberculosis: Helpful Hints for General Practitioners.
While tuberculosis (TB) is not common in Australia, each year 1200-1300 cases of TB are diagnosed nationally, of which almost 10%
are tertiary students and almost 5% are past or current healthcare workers (HCW). The majority of such cases, but not all, are born
overseas in countries with much higher rates of TB than we have in Australia.
Queensland Health requires all students who are to undertake placement in a clinical setting to complete a TB risk assessment
questionnaire to help identify active TB and latent TB. Those who are identified as being at risk, may present to their GP for further
assessment.
There are three main scenarios to consider.
A. Student self-reports symptoms which could be active TB
The symptoms as described on the risk assessment which may prompt a referral for assessment are one or more of the following:
1. Cough for more than 2 weeks (not related to an existing diagnosis or condition)
2. Unexplained fever for more than 1 week
3. Recent unexplained weight loss
4. Coughing up blood
5. Excessive sweating at night for more than one week.
As prolonged cough and haemoptysis may be features of pulmonary TB, it is recommended that such symptoms be identified at the
time of booking-in the patient (if possible), in order that appropriate infection control precautions may be implemented, such as the
patient waiting outside until called and the patient wearing a surgical mask when inside the practice (this reduces production of
infectious aerosols should the patient actually have TB).
You may prefer to promptly refer your patient to a public TB Control Unit (TBCU) (contact details below) where no further out of pocket
expenses will be incurred for the student. Similarly, a referral to a specialist experienced in TB medicine (usually a respiratory
physician or infectious diseases physician) may be considered.
Investigations which may be initiated from primary care, if undertaken, should include:
- Three expectorated sputum for “AFBs” (acid fast bacilli) – note sputa should be collected external to a GP practice or
pathology collection office (away from others) unless appropriate negative pressure facilities are available.
- A CXR (PA and lateral views).
If the CXR is abnormal or sputa are smear or culture positive for TB, referral to a TBCU or a specialist experienced in TB medicine is
recommended.
B. Student is asymptomatic but has risk factors that make latent TB more likely
In most cases, it is being born in a country with high TB incidence which makes TB infection more likely, but living in such countries for
a prolonged period and working in clinical or laboratory areas with increased potential exposure to TB are also risk factors.
People with latent TB are asymptomatic but they may progress to active TB including infectious pulmonary TB with a lifetime risk of
~10%. This risk can be reduced by 80 – 90% by administering antimicrobial therapy for 4 – 9 months (depending on the agent used).
Students with increased risk for latent TB are asked to present to a TBCU or GP for further testing.
Latent TB can only be diagnosed by a test which measures immune response to TB proteins; either an interferon-gamma release
assay (IGRA) or a tuberculin skin test.
The most practical test in general practice is the QuantiFERON® Gold Plus test (IGRA) as it requires a single blood sample, is done by
public and private labs and is unaffected by previous BCG vaccination.
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A negative IGRA test needs no further action in an asymptomatic student (NOTE: an IGRA test should not be used to exclude active
TB as it may be falsely negative).
A student with a positive IGRA test should be counselled regarding the pros and cons of preventative antimicrobial treatment. Active
TB should be excluded before treatment for latent TB is commenced. At this point referral to a TBCU or experienced TB clinician can
be considered for expert assessment and choice of preventative regimen (usually rifampicin or isoniazid daily therapy). A CXR prior to
referral is helpful- if the CXR is abnormal request a priority review.
As Medicare reimbursement for the IGRA is limited and considering that many overseas students may not be Medicare eligible, there
is often a charge for this test when ordered privately.
A tuberculin skin test can be performed by a TBCU. It is free of charge, but requires 2 visits to the clinic 48 – 72 hours apart and may
be positive due to past BCG vaccination rather than true latent TB.
C. Student is at increased risk of progression to active TB and more severe disease because they have a suppressed
immune system
There are many reasons for immune suppressed states including HIV infection, organ transplant anti-rejection drugs, connective tissue
diseases etc. Students are asked to identify whether they have an immune suppressing condition. If “yes” they should see their doctor
regarding testing for latent TB. A negative test is a useful baseline and a positive test should prompt discussion and offering of
preventative antimicrobial therapy.
Additional information including contact details for Queensland TB Control Units can be found on the Queensland Health Tuberculosis
Webpage at www.health.qld.gov.au/clinical-practice/guidelines-procedures/diseases-infection/diseases/tuberculosis
Student presents because of risks for active and/or latent TB
Symptoms consistent with active TB
Asymptomatic but risks factors for latent TB
• CXR (PA/Lat)
• 3 sputa on 3 separate days for “AFB
microscopy and culture”
Refer to TBCU for
TST and further
management
IGRA test
(Quantiferon
Gold Plus) *
NEGATIVE
CXR normal, No AFBS
on microscopy and no
Mycobacteria grown
Either CXR
abnormality
consistent with TB
OR AFBs on
microscopy or
Mycobacteria
grown
Discharge
Assess as for latent
TB if risk factors
Refer to QH TB Control Unit (TBCU) or Specialist
experienced in TB management
Implement appropriate infection
control precautions*
OR
POSITIVE or
INDETERMINANT
Consider CXR prior
to referral. IF CXR
abnormal, request
priority review
Queensland Health
* Infection control guidelines for the management of patients with suspected or conrmed pulmonary tuberculosis in
healthcare settings http://www.health.gov.au/internet/main/publishing.nsf/content/cda-cdi4003-pdf-cnt.htm
*Medicare listing for reimbursement of IGRA tests:
Test of cell mediated immune response in blood for the detection of latent tuberculosis by interferon gamma release
assay (IGRA) in the following people:
(a) a person who has been exposed to a conrmed case of active tuberculosis;
(b) a person who is infected with human immunodeciency virus;
(c) a person who is to commence, or has commenced, tumour necrosis factor (TNF) inhibitor therapy;
(d) a person who is to commence, or has commenced, renal dialysis;
(e) a person with silicosis;
(f) a person who is, or is about to become, immunosuppressed because of a disease, or a medical treatment, not
mentioned in paragraphs (a) to (e).
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Figure 1 Flow chart for TB Risk Assessment Management
