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    UKTB Consent

    Uploaded by

    Roha Javid
    This document is a consent form for applicants undergoing tuberculosis screening as part of the United Kingdom pre-entry program. It outlines that applicants must undergo an X-ray and possibly sputum tests, and if abnormalities are found further testing and potential treatment may be required. It details the testing and treatment procedures, costs, and information sharing policies. Applicants consent to testing and treatment if needed, and acknowledge the risks especially for pregnant applicants. Signatures are required from the applicant and guardian if applicable to confirm consent.

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    UKTB Consent

    Uploaded by

    Roha Javid
    549 views2 pages
    This document is a consent form for applicants undergoing tuberculosis screening as part of the United Kingdom pre-entry program. It outlines that applicants must undergo an X-ray and possibly sputum tests, and if abnormalities are found further testing and potential treatment may be required. It details the testing and treatment procedures, costs, and information sharing policies. Applicants consent to testing and treatment if needed, and acknowledge the risks especially for pregnant applicants. Signatures are required from the applicant and guardian if applicable to confirm consent.

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    This document is a consent form for applicants undergoing tuberculosis screening as part of the United Kingdom pre-entry program. It outlines that applicants must undergo an X-ray and possibly sputum tests, and if abnormalities are found further testing and potential treatment may be required. It details the testing and treatment procedures, costs, and information sharing policies. Applicants consent to testing and treatment if needed, and acknowledge the risks especially for pregnant applicants. Signatures are required from the applicant and guardian if applicable to confirm consent.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    549 views2 pages

    UKTB Consent

    Uploaded by

    Roha Javid
    This document is a consent form for applicants undergoing tuberculosis screening as part of the United Kingdom pre-entry program. It outlines that applicants must undergo an X-ray and possibly sputum tests, and if abnormalities are found further testing and potential treatment may be required. It details the testing and treatment procedures, costs, and information sharing policies. Applicants consent to testing and treatment if needed, and acknowledge the risks especially for pregnant applicants. Signatures are required from the applicant and guardian if applicable to confirm consent.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Annex E Consent form

    UNITED KINGDOM PRE ENTRY TUBERCULOSIS SCREENING PROGRAMME

    Name:
    Date of birth
    Clinic location:

    Applicant’s Declaration:
    I understand that:
     I am required to undergo testing for pulmonary tuberculosis (TB), involving an X-ray and
    possibly sputum tests, prior to applying for entry clearance to go to the UK;
     If my chest X-ray is abnormal, I will receive individual counselling and an explanation of
    the further testing procedures.
     If my chest X-ray is abnormal, and changes are suggestive of tuberculosis, regardless of
    whether these changes are old or new, or if there are other clinical reasons to suspect
    TB, I will have to provide three sputum samples which will be tested for TB with smear
    and culture. I understand that the results of sputum cultures may take up to ten weeks
     If sputum samples are necessary, I will be required to return for sputum collection on
    three consecutive mornings starting within seven (7) days of my chest X-ray. If I fail to
    return within seven days, I will forfeit the opportunity to obtain a TB Certificate.
     If the smear or culture shows the presence of TB bacteria, I will be referred for TB
    treatment. Treatment shall be at my own expense; I will inform the TB treatment facility
    that I have close family contacts, who may need evaluation for TB.
     I have the right to refuse to undergo the TB assessment procedure and TB treatment,
    but accept such a refusal may adversely impact on my UK visa application.
     I understand that the physician has the final decision about whether I receive a
    Certificate

    Female applicants.
    All female applicants will be asked about their last menstrual period to identify applicants
    who possibly may be pregnant:

     If I could be pregnant, I will be offered several alternatives; 1) a chest X-ray with


    protective shield; 2). I can postpone the CXR (and TB clearance) until after delivery
    or 3) I can opt to provide three sputum samples for laboratory examination.
     I acknowledge that a CXR can carry a risk for the unborn child, but that this risk is
    quite small in the second and third trimester. I am therefore advised to consult the
    panel physician and may wish to consult my gynaecologist to understand the risks
    before I take a chest X-ray. If I decide to submit to an X-ray, this shall be at my own
    risk.

    1
    I hereby:
     consent to undergo TB testing;
     authorise you and your designated laboratory to store all relevant personal information
    collected during the assessment process, including health records and chest X-ray;
     authorise you and your designated clinics to share my personal details and assessment
    results with the UK immigration authorities, the UK Department of Health, Public Health
    England and the UK National Health Service.
     I authorise you to share my assessment results with the health authorities of my country
    of residence, where this is required by my country’s laws.
     I release and hold harmless the UK Government and you from any liability for loss, injury
    suffered or other harm during, or as a result of, the TB assessment procedures

    I have read this consent form, or had translated for me. I was invited to ask questions to clarify
    what was not clear to me. I understand the content of this declaration.

    Applicant’s signature Date

    Please print your name

    For children, or adults without the mental capacity to give consent, I confirm that I am the parent or
    legal guardian of the applicant and confirm that I give my consent
    For adults who are not able to physically sign the form, I confirm that I am an independent witness
    and the applicant has given their consent orally or by other non-verbal means

    Signature Date

    Please print your name


    Relationship to applicant

    Statement of interpreter (if required); I have translated the content of this document for the
    applicant to the best of my ability and in a way in which I believe s/he can understand.

    Signed Date ……………….


    Please print your name)

    For female applicants who might be pregnant; I confirm that I have had the risks of having a chest
    X-ray in pregnancy explained to me and I wish to carry on with the chest X-ray.

    Signed Date
    Please print your name

    Statement of Physician (if required); I have explained the content of this document to the applicant
    and confirm that the applicant has declined to go ahead with the assessment.

    Signed Date
    Please print your name

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