Form NF 57-10-02 NF 57-10-02 Annual Tuberculosis Screening Document

OMB Control Number: 0648-XXXX
Expiration Date: XX/XX/20XX

NOAA Form 57-10-02
(1-22)

National Oceanographic and Atmospheric Administration
Office of Marine and Aviation Operations

Annual Tuberculosis Screening Document
NAME:

DOB:

DATE:

EMAIL ADDRESS :

PHONE:

EMPLOYMENT TYPE:

DUTY STATION/SHIP:

This form must be used to document the annual tuberculosis screening required by NOAA Policy 1008 of all persons seeking medical
clearance by NOAA Health Services. This form has three sections to include Section A: Tuberculosis History Screening, Section B:
Tuberculosis Testing, and Section C: Latent Tuberculosis Screening and Recommendations. Section A is required to be filled out by
any individual seeking clearance. Section B and Section C are only required if the healthcare professional performing the screening
deems them necessary. (If sections B and C have been completed and submitted to NOAA previously, no need to resend this
documentation unless new risk is disclosed).

Section A: Tuberculosis History Screening

Yes

No

Yes

No

To be completed by the individual
1

Do you have a history of a positive TB test, or a history of having TB?

2

Have you ever taken medication for the treatment of TB?
If so, when did you complete treatment? ___________

3

Were you born in a country with an elevated risk of TB? (listed below)

4

Have you recently traveled to a country with an elevated risk for TB?

5

At any time have you been exposed to someone diagnosed or suspected of having active TB?

6

Do you have a medical condition or undergoing treatment that affects the immune system?

7

Have you ever received an immunization for tuberculosis, commonly known as BCG?

8

Have you had any of the following in the past year?
a.

Unexplained Cough?

b.

Coughing up Blood?

c.

Unexplained Weight Loss?

d.

Unexplained Fatigue?

e.

Unexplained Fever?

f.

Unexplained Night Sweats?

1

NOAA Form 57-10-02
(1-22)

National Oceanographic and Atmospheric Administration
Office of Marine and Aviation Operations

Countries with an Elevated Risk of Tuberculosis
As per World Health Organization’s list of high burden countries 2019-2025
Angola, Bangladesh, Brazil, China, Democratic People’s Republic of Korea, Democratic Republic of the Congo, Ethiopia, India,
Indonesia, Kenya, Mozambique, Myanmar, Nigeria, Pakistan, Philippines, South Africa, Thailand, Uganda, United Republic of Tanzania,
Vietnam, Republic of the Congo, Gabon, Lesotho, Liberia, Mongolia, Namibia, Papua, New Guinea, Sierra Leone, Zambia

I certify that I have reviewed the foregoing information supplied by me and that it is true and complete to the best of my knowledge. I
authorize my primary care doctor, treating hospital, or prior clinics to furnish the Government a complete transcript of my medical record
for purposes of processing my application for this employment or service. I understand that falsification of information on Government
forms is punishable by fine and/or imprisonment.18 U.S. Code § 1001
SIGNATURE:

DATE:

Provider’s recommendation following tuberculosis screening
If the individual is found to be of minimal risk, no further action is needed. If further testing is recommended by the
healthcare professional, continue on to section B.
PROVIDER’S COMMENTS:

Tuberculosis risk assessment, based on above responses
Recommend Latent Tuberculosis Infection (LTBI) Testing

MINIMAL

INCREASED

NO

YES

PROVIDER’S CONTACT INFORMATION

PROVIDER’S PHONE:

PROVIDER’S NAME AND SIGNATURE

DATE:

STOP. Providers, if answers were ‘increased’ or ‘yes’ in the providers recommendation section above, continue on to section B
and C (or continue regardless of these answers if this is part of a new hire physical exam).

2

NOAA Form 57-10-02
(1-22)

National Oceanographic and Atmospheric Administration
Office of Marine and Aviation Operations

Section B: Tuberculosis Testing
To be completed by the healthcare professional performing the tuberculosis testing if indicated.

TST TEST RESULTS
DATE GIVEN
Lot #:

QUANTIFERON GOLD OR T-SPOT RESULTS

DATE READ

DATE TEST OBTAINED

Expiration:

TEST TYPE
____ QFT-G

Manufacturer:

RESULT

INTERPRETATION

____ MM INDURATION

___ POSITIVE

PROVIDER SIGNATURE AND DATE

____ T-SPOT

TEST RESULT
_____ NEGATIVE

____ POSITIVE

____ NEGATIVE

____ INTERMEDIATE/BORDERLINE

PROVIDER SIGNATURE AND DATE

Section C: Latent Tuberculosis Screening and Recommendation
To be completed by a healthcare provider.

NOAA policy requires that all persons with a recent or remote positive test for exposure to the tuberculosis
bacteria must obtain an annual physical examination by a licensed medical provider (physician, nurse
practitioner, or physician assistant) to determine if latent TB infection or active disease is present, and if persons
with latent infection are at high risk for developing active disease.
I have read the TST/Quant-G test or examined this patient and made the following determination:
Negative TST or Quant-G test no examination required.
Latent TB infection with low risk of developing active disease. No treatment intervention
recommended at this time.
Latent TB infection with high risk of developing active disease.
Prophylactic Medication(s) Prescribed: ______________________________________________________
Date Prophylactic Medication began ________ Date Prophylactic Medication will be completed _________

Active Tuberculosis.
PROVIDER COMMENTS:

PROVIDER CONTACT INFORMATION:

PROVIDER PHONE:

EXAMINATION DATE:

PROVIDER NAME AND TITLE:

PROVIDER SIGNATURE:

RESET
3

PRA Public Burden Statement A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor
shall a person be subject to a penalty for failure to comply with an information collection subject to the requirements of the
Paperwork Reduction Act of 1995 unless the information collection has a currently valid OMB Control Number. The approved
OMB Control Number for this information collection is 0648-XXXX. Without this approval, we could not conduct this
information collection. Public reporting for this information collection is estimated to be approximately 5 minutes per
response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the information collection. All responses to this information collection are required to
obtain benefits. Send comments regarding this burden estimate or any other aspect of this information collection, including
suggestions for reducing this burden to the Office of Marine and Aviation Operations, 1315 East West Hwy, Silver Spring, MD
20910.
PRIVACY ACT STATEMENT
Authorities: Privacy Act of 1974, 5 CFR Part 293, Personnel Records and Part 297, Privacy Procedures for Personnel Records;
Occupational Safety and Health Administration, 29 CFR 1910, Occupational Safety and Health Standards, Health Insurance
Portability and Accountability Act, Pub. L. 104-191.
Purposes: The health services you receive through this program result in the gathering and recording of information that is
personal and confidential. Your employing agency serves as a custodian of your records. Upon termination of employment the
original documents or copies of your records will be transferred to your Employee Medical Folder (EMF) in the agency’s
Employee Medical File System (EMFS). These records are stored as a distinct and separate part of your Official Personnel
Folder. Your records are collected and maintained for a variety of purposes, including:
•
to meet the mandates of law, Executive order, or regulations;
•
to provide data necessary for proper medical evaluations, treatment for the continuity of medical care;
•
to provide an accurate medical history and treatment and/or hazard exposures and health monitoring;
•
to enable the planning for further care;
•
to provide a record of communications among members of the health care team;
•
to provide a legal document describing the health care administered and exposure incidents;
•
to provide a method of evaluating the quality of health care rendered as required by professional standards and
legislative authority;
•
to ensure that all relevant, necessary, accurate, and timely data are available to support any medically-related
employment decisions;
•
to document claims filed with and the decisions reached in OWCP cases;
•
to document employee's reporting of occupational injuries, unhealthy and/or unsafe working conditions;
•
to ensure proper and accurate operation of the agency's employee drug testing program under Executive Order
12564.
Routine Uses: Information is collected to manage medical care and to maintain accurate and current medical records on
employees. Disclosure of this information is permitted under the Privacy Act of 1974 (5 U.S.C. Section 552a), to be shared with
applicable entities related to the purposes described above. Disclosure of this information is also subject to all of the published
routine uses as identified in the Privacy Act System of Records Notice, COMMERCE/NOAA–22, NOAA Health Services
Questionnaire (NHSQ) and Tuberculosis Screening Document (TSD).
Disclosure: Collection of this information is voluntary. If you do not wish to participate in these services, or to provide the
requested information, you are not required to do so. Non-NOAA personnel may decline to provide this information, but the
absence of documented medical clearances may prevent you from being cleared to embark on NOAA vessels or aircraft. For
NOAA personnel choosing to decline the health services required for job-related clearances, the absence of documented
medical clearances in will impact the employer’s authority to permit you to perform certain functions of your position. You
should consult with your supervisor in this matter.