To Whom It May Concern:

I hereby declare that, I, ____________________________________, withhold my consent on Tuberculosis screening on the grounds that such testing is in violation of my United States of America Constitutional 1st Amendment Right to religious freedom. It would be a violation of my religious beliefs to knowingly contaminate the body with inorganic and/or organic substances, such as the mycoplasma antigens, that can cause injury, illness, or other harm to my well-being.

I further assert the following:

I, _______________________ have not exhibited any of these of symptoms. There is no reason to suspect that I may be infected with Tuberculosis.

The CDC reports the following persons represent these high-risk categories for contracting TB:

I, _______________________ do not fall into any of these categories. The chance that I may be infected with Tuberculosis is minute and thus, provides no basis to suspect I may be infected with Tuberculosis.

Overall, I am a healthy adult who poses no serious, infectious health threat to others. My overall good health has been confirmed during visits to my primary physician and other healthcare givers.

I have included these assertions to show that by not being tested for Tuberculosis, I pose no threat to the health and well-being of others here at _______________________________________.



Notary Public:

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Signature Date

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City,                  State 	My Commission expires