Tuberculosis Control Commitment Form
Please complete this form to acknowledge your commitment to tuberculosis control measures. Your responses will help us ensure effective prevention and awareness.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Organization or Affiliation
Role or Position
Have you received information or training on tuberculosis control procedures?
*
Yes
No
Have you traveled to or worked in areas with a high incidence of tuberculosis in the past 12 months?
*
Yes
No
Have you undergone tuberculosis screening or testing in the past 12 months?
*
Yes
No
If yes, please specify the date of your most recent TB screening (leave blank if not applicable).
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Commitment
Should be Empty: