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ROYAL ADELAIDE HOSPITAL

Thoracic Medicine

SA TB Services

STUDENT QUESTIONNAIRE

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, valid for five years.

DO NOT COMPLETE THIS QUESTIONNAIRE MORE THAN ONCE!

The information you submit will be used only for the purpose of assessing your need for further TB screening. Once you fully complete and submit the questionnaire, you will be sent a follow-up email from SA TB Services within two weeks. All personal information will be held confidentially and securely by SA TB Services and will not be shared with any third parties. If you do not wish to complete this form online, please ring the Chest Clinic, 275 North Tce, Adelaide on 7077 2904.

Please fill in the details below ensuring all fields are correct before saving.

Cough
Fever
Weight loss
Respiratory Unit
Bronchoscopy Suite
Laboratory (manipulation of specimens)
Mortuary (manipulation of specimens)

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