Tuberculosis (TB): Forms

Wisconsin Tuberculosis Program Forms

Forms for the Wisconsin Department of Public Instruction

Per Wisconsin Statutes §118.25, school boards must require a physical examination as a condition of employment for all school employees. The physical examination must include a screening questionnaire for tuberculosis (TB), and if indicated, a test to determine the presence or absence of infectious TB disease. Please use the two forms below to fulfill these requirements and to document results for each employee. Please use the following instructions when completing these forms.

  1. Record of School Employee Examination, F-02284 (PDF)
  2. Wisconsin Tuberculosis (TB) Risk Assessment Questionnaire Screen for Wisconsin Public School Employees, F-02314A (PDF)

Questions regarding the two DHS forms above may be directed to the Department of Public Instruction State School Nurse and Health Services Consultant:

Louise Wilson, MS, BSN, RN, NCSN
School Nursing and Health Services Consultant
Wisconsin Department of Public Instruction
PO Box 7841
125 S. Webster St.
Madison, WI 53707

For more information or questions, contact the Respiratory Diseases and International Health Unit or your Wisconsin local health department.

Last Revised: November 4, 2019