Annual Employee Health Ppd/tb Screening Form - Black River Medical Center
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1Please take this form to the In-Patient Nurses Station and
they will be happy to assist you with your screening.
Then Return Form To Human Resources. Thank you!
Annual EMPLOYEE HEALTH PPD/TB SCREENING
Name: ____________________________________
Current Date: _____________________
Department: _______________________________
Employee Number: ____________
□ NO
□ YES
1.
Have you ever had a positive PPD/TB Test?
If you answered YES to #1:
□ NO
□ Yes _____
Are you positive for TB on lab testing (Quantiferon Gold)?
□ NO
□ Yes _____
Have you had a negative CXR since becoming positive for TB?
□ NO
□ Yes _____
Have you completed the recommended treatment for TB?
2. Are you taking antibiotics, steroids or immunosuppressive drugs? Are you immunosuppressed? □ No □ Yes
□ NO
□ Yes
3. Do you work in a department that is exempt from the PPD?
If you answered YES to #1, #2 or #3:
Do you have the following symptoms?
Cough lasting longer than 3 weeks □ No □ Yes/Explain ______________________________
□ No □ Yes/Explain ______________________________
Unexplained fever
□ No □ Yes/Explain ______________________________
Night sweats
□ No □ Yes/Explain ______________________________
Unexplained weight loss
□ No □ Yes/Explain ______________________________
Coughing up blood
□ No □ Yes/Explain ______________________________
Chest Pain
Employee Signature: ________________________________
Date: ______________________________
□ Annual
□ Exposure
□ New Hire
□ Volunteer
Reason for TB Screening
5 TU PPD (0.1 ml) Administered to □ Right
□ Left Forearm Lot# ________________________
Given by _______________________________________
Date ______________________________
Reading at 48 hours: _______________________ mm of indurations
Reading at 78 hours: _______________________ mm of indurations
Read by _______________________________________
Date ______________________________
□ Yes
□ No (No direct face-to-face patient interaction)
_____ Exempt Department---PPD Waived:
_____ New Hire ---Quantiferon Gold
Adverse Reaction
_____Positive PPD/Questionable PPD/Adverse reaction (circle one) --- Quantiferon Gold
_____Pregnant with MD Statement to omit PPD skin test---Quantiferon Gold
Immunosupressants
_____Antibiotics/Steroids/Immunosuppressant’s (circle one) ---Quantiferon Gold
_____Indeterminate Quantiferon Gold---Annual TB Screening Form
Results: □ positive
□ negative
Date Quantiferon ordered ____________________________
Date CXR ordered ___________________________________
Results: __________________________
F/U: _________________________________________________________________________________
Nurse Signature _____________________________________________________
Date ______________
Submit by E-mail
Print Form
IF YOU HAVE ALREADY HAD A PPD/TB TEST THIS YEAR PLEASE PROVIDE A COPY OF SHOT RECORD TO HUMAN RESOURCES
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