HomeMy WebLinkAbout106.073 - EMS-02, Tuberculosis Testing and Screening Program
ADMINISTRATIVE MANUAL
FORMS
106.073 TUBERCULOSIS TESTING/SCREENING
PROGRAM (EMS-02)
EFFECTIVE: OCTOBER 2014
Current Revision Date: 12/27/18 Next Revision Date: 12/27/19
Author’s Name/Rank: Jonathan Lopez-Galvan, Engineer Review Level: 1
PURPOSE
The Emergency Medical Services (EMS) form EMS-02 for is used to inform
members of the risks and benefits of receiving a Purified Protein Derivative (PPD)
test and the risks of acquiring tuberculosis (TB) from a work exposure.
APPLICATION
In order to meet the requirements of our annual TB testing program, all members
must complete a short questionnaire and sign indicating either Acceptance or
Declination of the PPD test once a year or as needed.
OPERATIONAL POLICY
The EMS-18 form is to be completed by the DICO and faxed to the appropriate
facility to meet the Department’s legal obligation to inform a facility of a possible
source patient with an aerosol transmissible disease. When this form is returned to
the DICO, it will be reviewed and a hard copy will be filed in a locked file cabinet, as
well as electronically filed in a secured “DICO Only” folder on the Training Division T
drive.
OPERATIONAL GUIDELINE
Members will submit the completed form in a sealed envelope to the Training
Division EMS Coordinator during the Department’s annual vaccination period.
PROCESS
During the annual vaccination period, a licensed health care provider will receive this
questionnaire electronically and review it to determine if further medical evaluation
and/or treatments are appropriate.
Section 106.073
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INFORMATION
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DEFINITIONS
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CROSS REFERENCES
Standard Operating Procedures Manual
Section 203.010a, Health Maintenance
Section 203.7, Injury and Illness Prevention Program
Section 106.073
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TUBERCULOSIS TESTING/SCREENING PROGRAM
Due to occupational exposure to mycobacterium tuberculosis, you may be at risk of
getting tuberculosis. Early detection is essential in effective treatment of the
disease.
When notified of a patient whom you and the crew have come in contact with, a
D.I.C.O. will interview you to determine if this is a high-risk situation. If so, you will
be offered a test at that time.
The Department will provide the PPD test to individuals. The incidence of serious
side effects from the testing is rare. A positive skin reaction may necessitate further
evaluation, which may include a referral to a physician, a chest radiograph, or
treatment with medications.
The current technique of administration is the Mantoux test. This test involves
injecting a solution of Purified Protein Derivative (PPD antigen) beneath the skin of
the forearm and creating a wheal. The presence or absence of the wheal will be
evaluated by a qualified Health Care Provider between 48 and 72 hours after test
administration.
The following individuals should not be tuberculin (TB) skin tested:
1. Those who received the Bacillus Calmette Guerin (BCG) vaccine
within the past three years,
2. Those with a history of a positive reaction to a previous tuberculin
skin test, a documented history of infection, or treatment for TB
per CDC guidelines.
To meet the requirements of the Department’s annual TB testing program, all
members must complete a short questionnaire and sign indicating either Acceptance
or Declination of the PPD test.
A licensed health care provider will review this questionnaire to determine if further
medical evaluation and/or treatments are appropriate.
Please submit completed form in a sealed envelope to the Training Division,
EMS Coordinator.
Section 106.073
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TUBERCULOSIS TESTING/SCREENING PROGRAM
NAME: Employee ID.#
Please answer the following questions:
During the past year, have you experienced any of the following?
YES NO
Traveled outside the United States
If yes, name of country
Weight loss (unrelated to dieting)
Persistent Cough (2-3 weeks duration)
Fever
Night sweats
Weakness or Fatigue
Coughing up Blood
TUBERCULIN (TB) SKIN TESTING ACCEPTANCE
The risks and benefits of receiving a PPD test and the risks of acquiring tuberculosis from a work
exposure have been explained to me. I acknowledge no guarantees have been made to me regarding
the effectiveness of this testing or the absence of adverse reactions to the testing. I understand this
information and have had all of my questions answered to my satisfaction. I understand I will receive
these services free of charge. I voluntarily give my consent to receive the TB skin testing.
Signature Date
TUBERCULIN (TB) SKIN TESTING DECLINATION (REFUSAL)
I have been given the opportunity to be tested for tuberculosis at no charge; however, I am
choosing to decline the PPD test at this time.
_ _ _ _
Signature Date
Reviewed by Health Care Provider:
Signed: Date:
Physician’s Initial:
Date:
SUBMIT COMPLETED FORM IN A SEALED ENVELOPE TO THE EMS COORDINATOR
Facility
Stamp
Section 106.073
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