Tuberculosis Screening Questionnaire
(To be completed by ALL students before class attendance at Salina Area Technical College)
ABOUT THIS FORM:

Tuberculosis, also known as TB, is a bacterial infection that attacks the lungs and, sometimes, other parts of the body. It is spread when someone infected with the disease coughs or sneezes and the bacteria is inhaled by someone nearby.

Pursuant to Kansas Statute KSA 2012 Supp. 65-129e, Salina Area Technical College requires students to complete a Tuberculosis Screening Questionnaire, to aid in prevention and control of Tuberculosis as required by State of Kansas Department of Health & Environment.

This is an important health issue so do not delay in obtaining further testing if indicated. SATC reserves the right to drop high risk and/or affected students from classes to ensure the safety of all students.

For additional information on TB: www.cdc.gov/tb/publications/factsheets/default.htm
Have you ever had a tuberculosis (TB) test that was positive? *
Have you ever received the BCG vaccine which is given outside the United States, to prevent tuberculosis (TB) *
Have you been in contact with anyone who has been sick with tuberculosis (TB) in the last 3 months? *
Were you born in a country NOT on the list below? *
Have you ever spent more than 3 months in a country NOT on the list below? *
You have answered "YES" to one or more of the above questions. For this reason, we are asking you to contact your local Healthcare provider or the Saline County Health Department at 785-826-6602 extension 166 to schedule an appointment to do further screening and/or testing. If a skin test is recommended by your Healthcare provider or the Health Department, it must be completed within two weeks of receiving this letter.

I acknowledge that I must have a current TB test performed and submitted to Salina Area Technical College prior to attending. *
To the best of my knowledge, the information provided above is true and complete. I am aware that deliberate misrepresentation may jeopardize my health and enrollment status. *
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Salina Area Technical College does not discriminate on the basis of race, religion, color, sex (including pregnancy and gender identity), sexual orientation, parental status, national origin, age, disability, family medical history or genetic information, military service, or any other non-merit based factor in admission or access to, or treatment in its programs and activities. Any person having inquiries concerning compliance with the regulations implementing Title VI, Title VII, ADA, Title IX, Section 504, Title II, GINA is directed to contact the Vice President of Operations, 2562 Centennial Rd, Salina, KS 67401, 785-309-3100.

For more information about our completion, on-time graduation rates, cost, placement rates, and median debt incurred, please go to http://www.salinatech.edu/ and search by program of study.

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