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.

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.

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.

• 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.

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.

• 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.