California Employee Tuberculin Skin Test Evaluation
This form is required for California Department of Corrections and Rehabilitation (CDCR) employees for tuberculosis (TB) screening and evaluation. It includes sections for employee information, TB history, skin test administration, blood tests, evaluation of symptoms, and chest X-ray results. Proper completion of this form ensures compliance with the TB screening requirements.
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How do I fill this out?
To properly fill out this form, all sections must be accurately completed according to the instructions provided. Both employee and health care provider need to fill out respective sections with appropriate details and signatures. Be sure to have all required documents ready for submission.
How to fill out the California Employee Tuberculin Skin Test Evaluation?
1
Complete Section 1 with employee information.
2
Health care provider completes Sections 2 to 7 as applicable.
3
Administer and document a Tuberculin Skin Test (TST).
4
Evaluate and document TB signs and symptoms in the provided sections.
5
Submit the completed form and required documents.
Who needs the California Employee Tuberculin Skin Test Evaluation?
1
New CDCR employees for initial TB screening.
2
Current CDCR employees for annual TB screening.
3
Employees requiring medically necessary TB evaluation.
4
Health care providers conducting TB screening for CDCR employees.
5
Employees with prior positive TB tests for follow-up evaluation.
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What are the instructions for submitting this form?
Complete the form accurately and ensure all necessary sections are filled. Both the employee and health care provider need to review and sign the form. Submit the completed form in a sealed envelope to the Business Information System. Please refer to your institution's specific mailing address or submission guidelines. It is advisable to keep a personal copy of the submitted form for your records.
What are the important dates for this form in 2024 and 2025?
Important dates for this form include the initial employment TB screening date for new hires and annual screening dates for current employees. Ensure you stay updated on your institution's specific dates to avoid any compliance issues.
What is the purpose of this form?
The primary purpose of this form is to ensure California Department of Corrections and Rehabilitation (CDCR) employees undergo the necessary tuberculosis (TB) screening and evaluation. This helps maintain a healthy work environment by identifying and managing TB infections early. The form must be filled out accurately by both employees and health care providers to comply with California state regulations. Regular TB screening is essential in correctional facilities to prevent the spread of TB. Employees with a positive test must undergo further evaluation and treatment if necessary. Utilizing this form keeps both employees and the general population safe. This form serves as a crucial document in maintaining workplace health standards by ensuring timely detection and treatment of tuberculosis. It plays a significant role in compliance with mandatory health regulations and helps in managing TB effectively within correctional facilities.
Tell me about this form and its components and fields line-by-line.
- 1. Employee Information: Includes employee's full name, gender, birthdate, PERNR, and other relevant details.
- 2. TB History and Treatment: Requires information on employee's TB history, prior treatments, and test results.
- 3. Tuberculin Skin Test (TST) Administration: Documents the administration and results of the Mantoux Tuberculin Skin Test.
- 4. TB Blood Test: Provides details on the TB blood test administration and results if applicable.
- 5. Evaluation for Signs and Symptoms: Includes a checklist of symptoms and the date and time of evaluation.
- 6. Chest X-Ray: Necessary for positive TB test results, includes X-ray results and report.
- 7. Evaluation: Final evaluation and comments from the health care provider, including signatures and license details.
What happens if I fail to submit this form?
Failure to submit this form can result in compliance issues and potential health risks.
- Non-Compliance: Failing to submit the form may result in disciplinary actions or non-compliance with state regulations.
- Health Risks: Incomplete or missing forms can lead to undiagnosed and untreated TB infections, posing health risks to others.
- Legal Consequences: Employees may face legal consequences for not adhering to mandatory TB screening requirements.
How do I know when to use this form?
- 1. Initial Employment: New employees must complete the form as part of the hiring process.
- 2. Annual Screening: Current employees are required to complete the form for their yearly TB test.
- 3. Follow-Up Tests: Used for follow-up evaluation after a positive TB test result.
- 4. Symptom Evaluation: Required if an employee exhibits symptoms indicative of a TB infection.
- 5. Post-Exposure: Needed if there has been known exposure to TB within the facility.
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