Tuberculosis Screening Certificate
Name: _________________________________________________________________
Last First Middle
Date of Birth: __________________
Month Date Year
Tuberculosis Risk Screening (check all that apply). Plant a Tuberculin Skin Test (TST) if has one
or more of risks listed.
Born in a high risk country (countries other than the US, Canada, Australia, New Zealand, or
Western European countries) and not had a documented negative TST.
Traveled for more than 1 week or lived more than 3 months in a high risk country since last
documented negative TST
(Plant TST when more than 10 weeks since return).
Has a family or household member or close contact who had a positive TST or active
tuberculosis since last documented negative TST
Client or a family or household member of close contact has been a resident in a congregate
living setting such as a shelter, prison, jail, nursing home or assisted living facility since last
documented negative TST
Has had close contact with person with a history of using IV drugs since client’s last
documented negative TST
Has had close contact with someone (including babysitter) from a high risk country since last
documented negative TST.
__________No risk factors identified, no Tuberculin Skin Test (TST) needed
__________Risk factor identified, TST required
__________TST results read: _____________Date ________mm.
__________Prior documented (+) TST, no TST planted
Additional information: ____________________________________________________
Signed:_________________________________________ Date___________________
Physician or designee
Northern Virginia Pediatric Associates, 107 North Virginia Avenue, Falls Church, VA 22046,
Office 703 532‐4446 Fax 703 532‐8426