Tuberculosis Exposure Risk Assessment 6224 NAVMED 8
User Manual: 6224
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3a. Check any countries where you have traveled or deployed to since your last Tuberculosis Exposure Risk Assessment.
2. Tuberculosis risk assessment, based on above responses
(If the answer to one or more of questions 1, 2, 3c, or 4b is a YES, test the patient.)
1. Since your last Tuberculosis Exposure Risk Assessment, were you exposed to anyone known to have or
suspected of having active tuberculosis (i.e., individuals with persistent cough, weight loss, night sweats,
and/or fever)?
2. Since your last Tuberculosis Exposure Risk Assessment or Post-Deployment Health Assessment (DD
Form 2796), did you have direct and prolonged contact with any individuals of the following groups:
refugees or displaced persons; patients hospitalized with tuberculosis , prisoners, or homeless shelter
populations?
3c. During this travel, did you have prolonged direct contact with the local population? Prolonged direct
contact is generally understood as having been within six feet of a person with a bad continuous cough for
at least 8 consecutive hours on a single day, or for a total of at least 15 hours per week of a multi-week stay.
FOR THE PROVIDER
(Expand on above answers to document decision making in determining risk)
(Note: Prior treated TST reactors require clinical evaluation to rule out active TB, not a repeat TST).
TUBERCULOSIS EXPOSURE RISK ASSESSMENT
HOSPITAL OR MEDICAL FACILITY
SPONSOR'S NAME
STATUS
SSN
DEPARTMENT / SERVICE
RELATIONSHIP TO SPONSOR
RECORDS MAINTAINED AT
PATIENT'S IDENTIFICATION: (For typed or written entries, give:
Name - last, first, middle; SSN; Sex; Date of Birth; Rank/Grade.)
NAVMED 6224/8 (Rev. 3-2011)
FOR THE PATIENT (Including those with previous positive tuberculin skin test)(Check the correct response)
PROVIDER'S NAME PROVIDER'S SIGNATURE DATE
Yes No
Yes No
Yes No Don't Know
1. Provider Comments
Bangladesh
Brazil
Cambodia
China
DR Congo
Ethiopia
India
Indonesia
Kenya
Mozambique
Burma
Nigeria
Pakistan
Philippines
Russian Federation
South Africa
Thailand
Uganda
UR Tanzania
Viet Nam
Zimbabwe
Other
If any of these listed countries are selected,
answer question 3c.
If "other" is checked, write in the name of the country
or countries.
3b. Have you recently traveled to Afghanistan for any reason other than as part of a deployment requiring
completion of a Post Deployment Health Assessment (PDHA)?
4b. If you marked YES to chronic cough, did you have any of the following at the same time?
Fever Cough up Blood Unexplained Weight Loss Night Sweats
If Yes, go to 3c.
Otherwise, go to 4a.
Yes No
If any are checked, see the medical officer for evaluation.
3. Recommend Latent Tuberculosis Infection (LTBI) Testing Yes No
Minimal Risk Increased Risk
4a. Have you recently had a chronic cough lasting more than 2 weeks? Yes No
None
FOR THE SCREENER
1. Questions 1 through 4 reviewed, all responses are negative, no further action is required.
2. There is at least one positive answer, patient to continue to medical officer for assessment.
Yes No
Yes No
