Mount Aloysius College Annual PPD Form
For Nursing and Health Studies Students
This form Must be completed by your health care practitioner
Name:
SECTION ONE
Two-Step Intradermal Mantoux PPD (TB Testing)
Before entering clinical all students must have a two-step PPD. The intradermal is given 2 consecutive weeks.
Every student who attends clinical must have a yearly PPD. If a student withdraws and comes back into the
program they must re-submit a two-step PPD again.
You must receive your PPD no more than 4 weeks before your deadline of_____________________________
The PPD cannot be given if a live virus (MMR or Varicella) vaccination is given within that 4-6 week time frame.
If a student needs to be vaccinated and it is less than 4 weeks before school begins, please refrain from giving the
live virus until after the PPD is given and before their clinical rotation begins.
Two-Step PPD
PPD # 1: Date Given:____________________Site: Left__________Right_____________
Administered by____________________________________
Lot #__________________Expiration date_________________
PPD #1 Result Date Read_____________________Positive _____Negative ____Results____mm
Read by ______________________________________________________
Student with a positive result must have a Chest X-Ray: Date of X-Ray:__________________
A copy of the chest x-ray report must be attached and dated within the year that the student attends clinical.
PPD # 2: Date Given:____________________Site: Left__________Right_____________
Administered by__________________________________
Lot #__________________Expiration date________
PPD #2 Result Date Read_____________________Positive ____Negative ___Results____mm
Read by _____________________________________________
Student with a positive result must have a Chest X-Ray: Date of X-Ray:__________________
A copy of the chest x-ray report must be sent and dated within the year that the student attends clinical.
SECTION TWO
Annual Intradermal Mantoux PPD (TB Testing)
Please make sure that you have a two-step PPD on file. If you have withdrawn and returned to campus you must
have the two- step repeated.
Your annual PPD must be done within one year of your initial two-step PPD.
Annual PPD
PPD Date Given:____________________
Site: Left__________Right_____________
Administered by___________________________________
Lot #__________________Expiration date________
PPD Result Date Read _____________________
positive _____Negative ____Results____mm
Read by ________________________________________
Student with a positive result must have a Chest X-Ray: Date of X-Ray:_______________
A copy of the chest x-ray report must be attached and dated within the year that the student attends clinical