Tuberculosis Testing Parental Consent Form For Tb Skin Test For Teens Form
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2St. Augustine Health Campus
Tuberculosis Testing
Parental Consent Form for TB Skin Test for Teens
Annual
New Volunteer (2-Step)
Name:
Department: VOLUNTEER
Start Date:
Date of Birth:
SS#
Parental/guardian permission is required for tuberculosis testing if under 18.
(No testing will be done without written parental permission if volunteer is under 18 years of age.)
I give permission for ________________________ to receive tuberculosis testing at St. Augustine Manor. I understand
there is no charge for this service.
Signature of Parent or Guardian: ____________________________________________ Date: __________________
Please answer the following questions about the volunteer/applicant:
1. Have you ever had Tuberculosis?
Yes
No
2. Has anyone close to you ever had Tuberculosis?
Yes
No
3. Have you ever had a reaction to the TB test?
Yes
No
4. Have you had stomach or intestinal surgery?
Yes
No
5. Were you born in the continental US?
Yes
No
6. Have you had the BCG vaccination for TB?
Yes
No
7. Are you in good health?
Yes
No
8. Is your immune system working well?
Yes
No
9. Are you taking steroids or cortisone?
Yes
No
10. Are you receiving radiation treatments or chemotherapy?
Yes
No
I understand that this test is required as a condition of my acceptance into the SAHC Volunteer Program. I am currently
not pregnant or nursing a baby and I am in good health. I understand that I must report back to have the test read.
Volunteer signature: ______________________________________________________ Date: ___________________
For the safety of our residents and employees, tuberculosis testing must be completed for ALL residents, staff and
volunteers. Initially, you must have a 2-step PPD (purified protein derivative) skin test before beginning work or volunteer
duties. Volunteers and volunteer applicants are asked to arrange times with the Volunteer Coordinator, Pat Finegan, at
(216) 939-7601.
You will receive a skin test in your forearm. You must return TWO days later to have your arm checked for a reaction.
New employees/volunteers must have a 2-step process that requires receiving a second skin test 7-14 days following the
first skin test. The reasoning for the 2-step is that the first injection will “sensitize” you. The second test will confirm a
positive or negative reaction. If you develop a “raised” reddened area at the site of the injection, you must return to St.
Augustine Manor at once. This could indicate that you have been exposed to tuberculosis at some point. A flat,
“reddened” area does not denote a “positive” reaction.
If you fail to have your TB test “read” according to the schedule, OR fail to have the second-step testing, you will have to
repeat the entire procedure. You will be tested annually, during your anniversary month, thereafter.
If you have questions or would like to schedule testing, please contact:
Pat Finegan, Volunteer Coordinator
St. Augustine Health Campus
(216) 939-7601 or
PPDs may be administered Monday through Wednesday after 9:30 p.m. by appointment only.
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