Uab Student Health & Wellness Tb Testing Form - Non-Clinical Domestic Students (Ppd)
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1UAB Student Health & Wellness TB Testing Form
Non-Clinical Domestic Students
NAME: ___________________________________________________________ DATE OF BIRTH: (mm/dd/yyyy): ________________
ADDRESS: ___________________________________________________________________ PHONE: _________________________
PROGRAM OF STUDY: _________________________________________________BLAZERID:_______________________@UAB.EDU
1. Tuberculosis: All students with a YES answer on the Tuberculosis Screening Questionnaire that you accessed on the Patient
Portal at
https://studentwellness.uab.edu/login_directory.aspx
“Forms” section, must meet UAB’s Tuberculosis Testing
requirement by completing the following evaluation:
•
You only need to have this testing and medical provider verification if you answered YES to any question on the
Tuberculosis Screening Questionnaire.
EITHER
a. Tuberculin Skin Test (PPD) within 3 months of matriculation: *
Date Placed: _____/_____/_____ Date Read: _____/_____/_____ Result (mm): __________ Positive: _____ Negative: _____
OR
a. IGRA (T-spot or Quantiferon TB Gold QFT-G) blood test within 3months of matriculation: *
Date: _____/_____/_____ Positive: _____ Negative: _____
1. Those with a positive PPD may elect to have a follow-up IGRA and UAB High Risk and Annual TB Questionnaire and if both are
negative then no further action is necessary, or student may elect to follow # 2 below.
2.* If positive skin test or IGRA result, Chest X-Ray and UAB TB High Risk and Annual Questionnaire required within 3 months of
matriculation.
a. Chest X-Ray** Date: _____/_____/_____ Normal: _____ Abnormal: _____ (*Please attach results)
b. UAB High Risk and Annual TB Questionnaire
c. Have you been treated with anti-tubercular drugs? Yes: _____ No: _____
If yes, type of treatment: _________________________ Length of Treatment: ____________________
Please attach supporting documentation.
**Please attach supporting documentation.
OR
a.
History of positive TB Skin Test (PPD) or blood test (IGRA: T-Spot or QFT-G)
PPD: Date Placed: _____/_____/_____ Date Read: _____/_____/_____ Result (mm): __________
IGRA: T-Spot_____
QFT-G_____
Date: _____/_____/_____ Positive: _____ Negative: _____
1. Those with a history of a positive PPD and not treated may elect to have a follow-up IGRA and UAB High Risk and Annual TB
Questionnaire within 3 months of matriculation, and if both are negative then no further action is necessary, or student
may elect to follow # 2 below.
2. Treatment completed? Yes___
Type of treatment____________________ Length of treatment_________________
Please attach supporting documentation
No___
Chest X-Ray** and UAB High Risk and Annual TB Questionnaire required within 3
months of matriculation.
Chest X-Ray** Date: _____/_____/_____ Normal: _____ Abnormal: _____ (*Please attach results)
** All TB testing and Chest X-rays must be performed in the U.S.
**PPD Interpretation Guidelines
≥ 5mm is positive:
≥10 mm is positive:
≥15 mm is positive if no risk factors
Recent close contact with person with active TB
Significant travel or residence in high prevalence area
Abnormal CXR c/w past TB disease
Illicit drug use
Organ transplant or other immunosuppression
Worker in healthcare, homeless shelter, prisons
HIV/AIDS
Chronic health issues
Verification of the above Student Immunization Record and Tuberculosis Screening by Health Care Provider:
Verified by: ____________________________________________ Title: _________________________________________________
Address_____________________________________________________________________________________________________
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