ROYAL ADELAIDE HOSPITAL
Thoracic Medicine

QUESTIONNAIRE: SA TB Services

Please complete the following questionnaire if you are a Health Care student
studying in SOUTH AUSTRALIA.

This is a one time requirement prior to FIRST placement, that is good for five years.

DO NOT COMPLETE THIS QUESTIONNAIRE MORE THAN ONCE!
For concerns ring 8222 5307

The information you submit will be used only for the purpose of assessing
your need to attend SA TB Services for further TB screening.
All personal information will be held confidentially and securely by SA TB Services
and will not be shared with any third parties.
Once you fully complete and submit the questionnaire,
you will be sent a follow-up email from SA TB Services within two weeks.
If you do not wish to complete this form online,
please attend the Chest Clinic, 275 North tce, Adelaide

Surname

Given Name
Date of Birth
Male  Female
Email

re-enter Email
Address

Suburb

Postcode
Home Telephone
Mobile
Local Doctor
Ethnicity
Aboriginal   Asian   African   Caucasian   Other  
Country of Birth

Date of Arrival
Visa/residency status
Permanent Resident   Temporary Resident   Australian Citizen  
Visa Type
Work   Student  
Institution/University, currently enrolled
Future employer/placement institution
Leave blank if unknown.

Course/Placement position

Commencement
Have you ever been in close contact with someone who has TB?
Yes  No
Have you ever had tuberculosis in the past?
Yes  No
Have you been screened in Australia for TB in the past 5 years?
Yes  No

Questionnaire submission will take some time,
please wait until the confirmation screen comes up,
and do not press the Submit button again.

http://www.pages.on.net/questionnaire.php
was last modified: June 22 2017 21:48:49.
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