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 1^st 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:
  1. Coughing up blood/ Chest infection
  2. Severe weight loss
  3. Night sweats
  4. Constant exhaustion
  5. 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 Abusers

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 _______________________________________.

Sincerely,

______________________

Notary Public:

__________________________        ______________________ _

Signature                                              Date

__________________________        ______________________ _

City, State                                             My Commission expires