Record Of Tuberculosis Screening Form (Ppd)
Download a blank fillable Record Of Tuberculosis Screening Form (Ppd) in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Record Of Tuberculosis Screening Form (Ppd) with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1SECTION 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.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical