Mandatory Immunization Form (Page 2 of 2) in pdf

TWO STEP TUBERCULOSIS SCREENING

(Must be completed within 12 months prior to entering program)

Student Name:____________________________ Date of birth:_________________________

**Quantiferon Tuberculosis Testing can be done in lieu of PPD**

A documented negative Quantiferon –TB Gold blood test within 12 months prior to start of program will substitute for

□

two step PPD screening below.

I have attached a negative quantiferon –tb gold lab result to this form.

STEP ONE:

STEP TWO: (must be at least 7 days and no longer then 12

Baseline skin test placed: _____ / _____/ _____

months from step one PPD)

Skin test placed: _____ / _____/ _____

Baseline skin test read: _____ / _____ / _____

Skin test read: _____ / _____ / _____

Results in millimeters:

_____________ mm

Results in millimeters: __________mm

If test is negative proceed with step two.

If secondary PPD is positive, a copy of your chest x-ray must

If test is positive you do not need to complete step two.

be attached

If test is positive, a copy of your chest x-ray must be attached

Prophylactic treatment for positive PPD: Yes _____ No ____

Treated with: _____________________ x _______ months

Completed treatment date: _____ / _____ / _____

I certify that the information above is complete and accurate to the best of my knowledge:

Healthcare Provider Printed Name __________________________________Date ____________

Healthcare Provider Signature _____________________________________

Office Phone Number (

) __________________________________

Office Address __________________________________________________

__________________________________________________

Mandatory Office or Healthcare Provider Stamp:

Return completed form prior to start of program to:

Specific College and/or Program in which you will be enrolling

NSU Health Professions Division

3200 S. University Drive Ft. Lauderdale, Fl 33328

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Mandatory Immunization Form Page 2