SECTION B (CONSENT FOR PPD TB SKIN TEST)
I ______________________________________________consent to have a PPD Tuberculosis skin test. I
release TDY MEDICAL STAFFING, INC. and its employees from all liability in connection with the
administration and interpretation of this test.
Employee Signature: _______________________________________ Date: ___________________
Witness: _______________________________________ Date: ___________________
SECTION C (FOR ONE STEP/ANNUAL TB TESTING)
This is to certify that the above named person (a) had a Tuberculin Skin Test on ____/_____/_____ which
was read as __________mm. on ______/______/______.
Signature MD/RN: _________________________________________ Date: ___________________
Address: __________________________________________________
SECTION D (FOR TWO STEP TB TESTING)
This is to certify that the above named person (a) had a Tuberculin Skin Test on ____/_____/_____ which
was read as __________mm., on ______/______/______, and (b) had a second Tuberculin Skin Test
on____/_____/_____ which was read as __________mm., on ______/______/______. This completes the
two step Tuberculin Skin Testing process and the individual is classified as uninfected.
Signature MD/RN: _________________________________________ Date: ___________________
Address: __________________________________________________
SECTION E (FOR POSITIVE READING)
This is to certify that the above named person (a) had a Tuberculin Skin Test on ____/_____/_____ which
was read as __________mm., on ______/______/______, and (b) had a chest x-ray on _____/______/
______ (if applicable must send copy of radiology report) which showed no sign of active inflammatory
disease. This person has no symptoms suggestive of active tuberculosis, no known exposure to
tuberculosis, and has completed adequate TB related surveillance. Therefore, a two-step Tuberculin Skin
Test for tuberculosis is not indicated at this time.
Signature MD/RN: _________________________________________ Date: ___________________
Address: __________________________________________________
CXR per CDC Guidelines: Employee to complete questionnaire annually. CXR does not
have to be repeated unless employee becomes symptomatic or repeat CXR is
recommended by the MD.