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Your Information

Please enter your contact information

First Name * 🛈

Last Name *

Phone Number *

Email Address *

5 digit employee badge number *

Yearly TidalHealth Volunteer TB questionnaire

Please answer all of the following questions

1) Do you have persistent COUGH for more than 2 weeks? *

Yes

No

2) Do you have persistent BLOODY SPUTUM production? *

Yes

No

3) Do you have persistent UNEXPLAINED WEIGHT LOSS? *

Yes

No

4) Do you have persistent UNUSUAL FATIGUE? *

Yes

No

5) Do you have persistent SWOLLEN GLANDS? *

Yes

No

6) Do you have persistent POOR APPETITE? *

Yes

No

7) Have you had a positive TB skin test? *

Yes

No