Tuberculosis (Tb) Testing Form - 2012
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1Student Name: ______________________________________
Student ID #: _________________________
TUBERCULOSIS (TB) TESTING FORM
Based on your answers to the online Tuberculosis Questionnaire, you are required to have further testing for
tuberculosis. Please print this form and take it to your medical provider for completion.
STEP 1:
You are REQUIRED to have a tuberculosis test BEFORE you arrive on campus. It must be done
even if you have had a Bacille Calmette-Guérin (BCG) immunization. The test may be a purified
protein derivative (PPD) or an interferon-gamma release assay (IGRA), such as a QuantiFERON®-
G, QuantiFERON®-GIT, or a T-SPOT® test.
PPD Administered (date): __________
PPD Interpreted (date): __________
PPD Result: __________ mm induration
Interpretation:
positive
negative
IGRA Name:
______________________________
IGRA Date: _____________________
IGRA Results: please attach a copy of the IGRA report, including Nil value, TB response, and
mitogen response.
IGRA Interpretation: positive*
negative
indeterminate*
*IF THE TUBERCULOSIS TEST IS POSITIVE OR INDETERMINANT, GO TO STEP 2. If it’s negative, go to STEP 3.
Step 2:
You are REQUIRED to have a chest x-ray BEFORE arriving on campus. Once it is done, attach a
copy of the x-ray report and proceed to STEP 3.
Chest X-ray result: ___________________________________________________________
Chest X-ray date: _______________
*please attach copy of x-ray report
Step 3:
Please have healthcare provider give their contact information and sign this form.
Healthcare Provider Name (printed):
__________________________________________
Address:
__________________________________________
Phone #:
__________________________________________
Fax #:
__________________________________________
Healthcare Provider Signature: __________________________________________________________
Step 4:
Mail or fax this form to:
SUNY Potsdam Student Health Services
44 Pierrepont Avenue
Potsdam, NY 13676
Phone: 315-267-2377
Fax:
315-267-3260
Created: REM 6-12
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