Tuberculosis Screening Form - Department Of Education printable pdf download

Department of Education

Tuberculosis Screening Form

Please have this form completed properly, then submit it to the worksite whose payroll Turnaround Document lists your

name by __________________________. This is necessary to comply with Section 25103, title 10, Guam Code

Annotated, which requires you to be screened for tuberculosis as a condition of employment or doing volunteer work, and

annually thereafter. Failure to do so by the date given above can be grounds for placing you on leave without pay until the

required documentation is submitted.

Please note the following:



The items on this form require that they be completed within a certain time period to be valid. Different items have

different time periods.



Applicants for employment must first submit a copy of this form to the Personnel Services Division, then, upon

hiring, also provide a copy to the stated worksite.

============================================================================================

Name of Employee _____________________________________________________ Date of Birth _______________

(Last)

(First)

(Middle)

Social Security # __________________________ Work Location ____________________________________________

============

DIRECTIONS

============

Completely read the following items and do what is indicated by them; many require you to continue to another item. Items

shown in small print must be completed by a physician, physician’s assistant (PA), nurse practitioner (NP), or nurse; refer to

each item for specifics.

1. If you are not a positive TB test reactor: start with Item 2.

If you are a positive TB test reactor but have not received treatment for TB, start with Item 6.

If you are under or have received treatment for TB: do Item 9.

2. Obtain a PPD skin test and have the following information completed. Then do item 3. (The result must be less

than a year old on the date indicated at the top to be valid. You may attach other medical documentation to this

form which shows the date of administration Obtain a PPD skin test and have the following information completed.

Then do item 3. (The result must be less than a year old on the date indicated at the top to be valid. You may

attach other medical documentation to this form which shows the date of administration and reading of a PPD

instead of having this item completed. However, all other items which apply to your situation must be properly

completed on this form.)

Date administered: _______________________

Date read: ______________

Result: ________mm

______________________________________

__________________________________

Name of physician/PA/NP/nurse (print)

Signature of physician/PA/NP/nurse

3. a).If the result from Item 2 is 0-9 mm or negative, disregard the following items.

b) If the result of Item 2 is 10 mm or greater: do Item 4.

4. Obtain a chest X-ray and: a) have the following completed by only a physician, PA or NP; and b) attach a radiology

report concerning the X-ray from a licensed radiologist. Then do Item 5. (If this is done in compliance with Item 3:

the X-ray must have been conducted no sooner than six months prior to the PPD required by item 2 to be

considered valid. If this is done in compliance with Item 6: the X-ray must have been conducted no sooner than

Continued……

Tuberculosis Screening Form - Department Of Education

Related Articles

Related forms

Related Categories