ROYAL ADELAIDE HOSPITAL

Thoracic Medicine

SA TB Services

STUDENT QUESTIONNAIRE

Please complete the following questionnaire if you are a Health Care student studying in SOUTH AUSTRALIA.

This is a one time requirement prior to FIRST placement, valid for five years.

DO NOT COMPLETE THIS QUESTIONNAIRE MORE THAN ONCE!

The information you submit will be used only for the purpose of assessing your need for further TB screening. Once you fully complete and submit the questionnaire, you will be sent a follow-up email from SA TB Services within two weeks. All personal information will be held confidentially and securely by SA TB Services and will not be shared with any third parties. If you do not wish to complete this form online, please ring SA TB Services, Royal Adelaide Hospital, on 7117 2900.

Please fill in the details below ensuring all fields are correct before saving.

Surname

Given Name

Date of Birth

Gender

Male

Female

Re-enter Email

Address (Local SA)

Suburb

Postcode

Home Telephone

Mobile

Local Doctor

Ethnicity

Aboriginal, ATSI, TSI, or other Indigenous Australian

Asian

African

Caucasian

Other

Country of Birth

Date Of Arrival

Visa / Residency Status

Permanent Resident

Temporary Resident

Australian Citizen

Visa Type

Work

Student

Institution / University, currently enrolled

Future employer / Placement Institution

Course / Placement position

Commencement

Have you ever been in close contact with someone who has TB?

Yes

Have you ever had tuberculosis in the past?

Yes

If Yes, When?

Were you treated?

Yes

Have you been screened in Australia for TB in the past 5 years?

Yes

Do you have any of the following symptoms?

Cough

Yes

Fever

Yes

Weight loss

Yes

Have you worked or lived outside of Australia for periods of more than 3 months?

Yes

Have you ever been involved in the care of patients with TB?

Yes

If yes, please give details

Have you ever worked in any of the following work units?

Respiratory Unit

Yes

Bronchoscopy Suite

Yes

Laboratory (manipulation of specimens)

Yes

Mortuary (manipulation of specimens)

Yes

Have you had any vaccinations in the last 4 weeks?

Yes - If you have had a live vaccination, you must wait 4 weeks before you can have TB screening. (MMR, Varicella (chicken pox), Yellow Fever).

If yes, please list

Have you had any of the following medical conditions?

Yes

Chronic renal disease

HIV Infection

Chronic lung disease

Cancer

Autoimmune

Are you currently taking any of the following?

Yes

Steroids

Other immune-suppressants

Chemotherapy

If yes, please give details

Do you have any allergies?

Yes

If yes, please give details

Have you had a BCG tuberculosis vaccination?

Yes

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