Pediatric TB Risk Assessment Form

Central Illinois Pediatric Associates

Please correct the errors described below.
  • I currently in jail or who has been in jail in the past 5 years?
  • Has HIV?
  • Is Homeless?
  • Lives in a group home?
  • Uses illegal drugs?
  • Is a migrant farm worker?

If yes, to any of the above, the child has an increased risk of TB infection and should have a TB Skin Test/IGRA.

Adapted from IDPH Pediatric TB risk assessment form.

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