Form Deh-001 - Health Certificate Clearance Application Page 3
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3POSITIVE REACTOR STATUS REPORT
THIS FORM MUST BE COMPLETED AND SUBMITTED WITH THE TB EVALUATION
CLEARANCE FORM ONLY IF THE PPD SKIN TEST IS POSITIVE.
NAME: ________________________________________________ DOB: __________________________
ADDRESS: _______________________________________________________________________________
ETHNICITY: _____________________________ PHONE (HOME/WORK): _______________________
1.
PPD Test: Date Given: _____________
Date Rec’d: ______________ Result: ________ mms
2.
Chest X-ray: Date: _________________
Normal __________
Abnormal ______________
*Note: Radiological Interpretation by Licensed Radiologist Must be attached.
3.
INH Preventive Therapy Offered: Yes _______ No __________
4.
Patient is currently on INH Preventive Therapy at my clinic.
Yes _______
No ________ Date Preventive Therapy Started: _______________________
5.
If not on INH Preventive Therapy, please state reason:
____ a. Patient refuses INH Preventive Therapy offered.
____ b. Patient is over 35 years of age with no risk factor.
____ c. Other (Specify) _____________________________________________________
6.
Patient cleared for work/school: Yes ________ No ___________
7.
Patient referred to DPHSS Communicable Disease Control Clinic for possible INH Preventive Therapy.
Yes _______
No ________
8.
Patient referred to DPHSS Communicable Disease Control Clinic for possible active TB.
Yes _______
No ________
9.
Comments: __________________________________________________________________________
_______________________________________________
________________________
Physician’s Signature
Date
_______________________________________________
Name of Physician/Clinic (Print)
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