Uab Student Health And Wellness Health History Form Page 4
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45. Tuberculosis: All students must meet UAB’s Tuberculosis screening requirement. If no history of positive Tb skin test, two
separate skin tests or one IGRA blood test are required upon matriculation. Skin tests must be placed at least one week apart.
*ALL TB TESTING (skin, blood, CXR) MUST BE PERFORMED IN THE U.S.
EITHER
a.
Tuberculin Skin Test (PPD) within 3 months prior to matriculation:
Date Placed: _____/_____/_____ Date Read: _____/_____/_____ Result (mm): __________ Positive: _____ Negative: _____
b. If first Tuberculin Skin Test (PPD) negative, second skin test is required. Must be placed at least 1 week after the first
test and within 3 months prior to matriculation:
Date Placed: _____/_____/_____ Date Read: _____/_____/_____ Result (mm): __________ Positive: _____ Negative: _____
OR
a.
IGRA (Tspot or Quantiferon TB Gold) blood test and UAB TB Questionnaire within 3 months prior to matriculation:
Date: _____/_____/_____ Positive: _____ Negative: _____
b. UAB TB Questionnaire
*If positive skin test or IGRA result, Chest X-Ray within 3 months prior to matriculation and UAB TB Questionnaire required.
a. Chest X-Ray Date: _____/_____/_____ Normal: _____ Abnormal: _____ (*Please attach results)
b. UAB TB Questionnaire
c. Have you been treated with anti-tubercular drugs? Yes: _____ No: _____
If yes, type of treatment: _________________________ Length of Treatment: _________________________ *Please attach
supporting documentation.
Verification of the above Student Immunization Record and Tuberculosis Screening by Health Care Provider:
Verified by: _______________________________________________________ Title: ______________________________________
Address: ____________________________________________________________________________________________________
Phone: __________________________________
Signature: _________________________________________________________________ Date: _____/_____/_____
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