Immunization Record - Tuberculin Skin Test (One Step)
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Undergraduate Medical Education
Immunization Record – Tuberculin Skin Test (One Step)
Many of you will apply for elective and/or residency. In some cases, you will be asked to submit proof of a
PPD test performed within the last 12 months of the date of the beginning of your elective and/or residency.
For those of you who prefer to have a PPD test performed outside McGill Student Health Service, but wish
to have that information included in your medical record at Student Health Service, please have the
following form completed by the health professional performing the test and forward it back to us.
Last Name:
First Name:
Student ID #:
Year of Study:
(Circle): 2 ‐ 3 – 4 ‐ Resident
Trainee Authorization: I give my consent that the information on this form may be released to my faculty
or any teaching hospital and administrative staff in the McGill system upon request.
Signature of student:
Date:
MM / DD / YYYY
Date of TB Test PLANTING:
MM / DD / YYYY
Signature:
Date of TB Test READING
MM / DD / YYYY
Signature:
(48‐72hrs after planting):
Reading
RESULT:
Negative: Positive*:
_______ mm
(induration):
Result:
Date of IGRA if performed
MM / DD / YYYY
instead of PPD:
Signature:
*Chest X‐Ray and respirologist consultation: (Required ONLY if above test is POSITIVE)
Chest X‐ray Date:
Results:
Normal: Abnormal:
Name of
Respirologist consult date:
respirologist:
Comments:
Clinic/Health Center Authorization:
(Name, Address and phone number of
center where form was completed)
Signature:
Date:
MM / DD / YYYY
(Trainee may not sign form)
If completed outside Student Health Service, please FAX the completed form to 514‐398‐2559 or
MAIL to: McGill Student Health Services, 3600 McTavish Rm: 3301 Montreal, Quebec, H3A‐1Y2
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