Pediatric TB/LEAD Exposure Risk Assessment

Child's Name

Child's Age*

Today's Date

TB Questionnaire

Has a family member of anyone the child is in contact with on a regular basis been diagnosed or suspected of being sick with active TB disease?

Yes
No

Does the child have a family member or frequent visitor who was born in a high TB prevalence country (most countries - Asia, Africa, Latin America, part of Eastern Europe)?

Yes
No

Was the child born in or traveled to high TB prevalence countries (most countries - Asia, Africa, Latin America, part of Eastern Europe)?

Yes
No

Does the child live in an out of home placement such as foster care or residential facilities?

Yes
No

Does the child have HIV/AIDS infection or any other immunosuppressive condition?

Yes
No

Does the Child live with an adult with HIV/AIDS or any other immunosuppressive condition?

Yes
No

Does the Child live or frequently visit the person(s) who have been incarcerated in the last 5 years (five):

Yes
No

Has the child lived among or been frequently around individuals who are homeless, migrant, workers, users of street drugs or residents in nursing homes?

Yes
No

LEAD Questionnaire

Was the child's daycare center/preschool/baby-sitter's building built before 1960?

Yes
No

Does the house have peeling or chipping paint?

Yes
No

Has the child ever lived in a house built before 1960 with recent, ongoing, or planned renovation or remodeling?

Yes
No

Have any of the children living with the child on their playmates had lead poisoning?

Yes
No

Does the child frequently come in contact with any adults who work with lead? Examples include construction, welding, pottery, or other trades practiced in your community.

Yes
No

Do you give the child home or folk remedies that may contain lead?

Yes
No

Does your child live near a heavily traveled major highway where soil and dust may be contaminated with lead?

Yes
No

Does your homes plumbing have lead pipes or copper pipes wih lead solder joints?:

Yes
No

Does your child live near a lead smelter, battery recycling plant, or other industry likely to release lead?

Yes
No

Do you use dishes and cups which come from outside the United States which might have a lead glaze?

Yes
No