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.
The Tuberculin Purified Protein Derivative (Mantoux skin test). Tubersol™ determines that a person has been previously exposed to or had a previous infection by M. tuberculosis or a variety of non-tuberculosis bacteria. A positive reaction may also represent an allergic reaction to the components of the test. It cannot tell whether a person has active tuberculosis disease.
Tubersol™ contains Tween 80™ as preservatives. A very recent study (December, 2005) discovered that Tween 80™ , also known as polysorbate 80, can cause anaphylaxis, a potentially fatal reaction characterized by a sharp drop in blood pressure, hives, and breathing difficulties in persons previously exposed. Researchers concluded that the anaphylactic reaction was not a typical allergic response caused by histamines and IgE antibodies, but it was caused by a serious disruption that had occurred within the immune system. REF: Coors, Esther A, et. al."Polysorbate 80 in medical products and nonimmunologic anaphylactoid reactions." Annals of Allergy, Asthma and Immunology. 95 (2005): 593-599.
I further assert the following:
There is no tuberculosis epidemic in ___________________________[city] to warrant the mandate of such testing
There is no tuberculosis crisis at the ___________________________ to warrant the mandate of such testing
Symptoms commensurate with tuberculosis are known to be:
Coughing up blood/ Chest infection
Severe weight loss
Loss of appetite
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:
Those coming into close contact with persons known or suspected to have TB
Foreign-born persons from areas where TB is common: Asia, Africa, or Latin America
Elderly persons (over 65 yrs.)
Health care worker who serves high risk patients—AIDS, TB, indigent
Healthcare worker in close contact with medically underserved, low income populations
I am not an Intravenous Drug Abuser
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 _______________________________________.
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City, State My Commission expires