Form 032-05-420/8 Report Of Tuberculosis Screening Children'S Programs
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1REPORT OF TUBERCULOSIS SCREENING
CHILDREN’S PROGRAMS
Standards and child care policy require certain individuals to submit a report indicating the absence of tuberculosis in a
communicable form when involved with (i) children’s facilities regulated by the Department of Social Services or (ii)
legally operating child care programs, excluding care by relatives, that receive Child Care and Development Funds.
Each report must be dated and signed by the examining physician, the physician’s designee, or an official of a local
health department.
When signed by the physician’s designee, the form must also identify the physician/physician
practice with which the physician –designated screener is affiliated.
Name: _________________________________________
Date of Birth: _________________________
Address (Street, City, State, Zip Code):
____________________________________________________
_______________________________________________________________________________________
1).
____ A tuberculin skin test (PPD) is not indicated at this time due to the absence of symptoms
suggestive of active tuberculosis, risk factors for developing active TB or known recent contact
exposure.
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2).
Tuberculin Skin Test (PPD): Date given: __________
Date read: _________
Results: _______ mm
Positive: ________ Negative: ________
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3).
____ The individual has a history of a positive tuberculin skin test (latent infection). Follow-up
chest x-ray is not indicated at this time due to the absence of symptoms suggestive of active
tuberculosis.
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4).
____ The individual either is currently receiving or has completed medication for a positive
tuberculin skin test (latent TB infection) and a chest x-ray is not indicated at this time. The individual
has no symptoms suggestive of active tuberculosis disease.
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5).
____ The individual had a chest x-ray on ___________ (date) at ________ _____________________
(location) that showed no evidence of active tuberculosis. As a result of this chest x-ray and the
absence of symptoms suggestive of active tuberculosis disease, a repeat film is not indicated at this
time.
Based on the available information, the individual can be considered free of tuberculosis in a
communicable form.
Signature/Title: _________________________________________________
Date: ___________
(MD/designee or Health Department Official)
_________________________________________________
(Print Name/Title)
Address (including name of practice, if appropriate):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Telephone number: ________________________________________________________
032-05-420/8 (6/05)
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