Report Of Tb Screening Form
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1Virginia Department of Health
REPORT OF TUBERCULOSIS SCREENING
DATE ______________________________
Name ________________________________________
Date of Birth _______________
To Whom It May Concern:
The above named individual has been evaluated by ________________________________
(Name of health dept./facility)
Tuberculin Skin Test (TST)
Date given: _______________
Date read: _______________
Results: ______mm
___ Negative
___ Positive
The individual listed above has no symptoms compatible with active tuberculosis. The
individual is free of tuberculosis in a communicable form.
Signature ______________________________
Date ___________________________
(MD or Health Department Official)
Address ________________________________
Phone ___________________________
City, State, Zip ______________________________________________________________
Interferon Gamma Release Assay
Alternative test for the tuberculin skin test (TST)
Date drawn ________________
Time drawn ___________________
Result:
___Neg
___Pos
___Indeterminate
___Borderline
The individual listed above has no sympotms compatible with active tuberculosis. The
individual is free of tuberculosis in a communicable form.
Signature ______________________________
Date ___________________________
(MD or Health Department Official)
Address ________________________________
Phone ___________________________
City, State, Zip ______________________________________________________________
Chest X-Ray – No active disease
Date of Chest x-ray _______________
___ No evidence of active tuberculosis
The individual listed above has no symptoms or radiographic findings compatible with active
tuberculosis. The individual is free of tuberculosis in a communicable form.
Signature ______________________________
Date ___________________________
(MD or Health Department Official)
Address ________________________________
Phone ___________________________
City, State, Zip ______________________________________________________________
Chest X-Ray – Abnormal Report
Date of Chest x-ray _______________
___ Chest x-ray abnormal, active tuberculosis to be ruled out
Active tuberculosis cannot be ruled out in the individual listed above. The individual should
be referred to a physician or health department for further evaluation.
Signature ______________________________
Date ___________________________
(MD or Health Department Official)
Address ________________________________
Phone ___________________________
City, State, Zip ______________________________________________________________
March 2011
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