X-Ray Certificate For Temporary Entry (Inz 1096) (Page 4 of 4) in pdf

X-Ray Certificate For Temporary Entry (Inz 1096) Page 4

When filling in this form, please print clearly using CAPITAL LETTERS.

Passport/identification number

Radiologist/radiographer initials

Section D

Chest X-ray results for person having the examination

Comment is required on any and all aspects found not to be entirely normal with regard to TB.

Give a full description of all TB-related findings.

Also provide details of any other (non-TB-related) abnormalities that may be evident.

Is there evidence of TB?

Yes

Provide details below

Go to

Is this evidence of old, healed TB?

Yes

Provide details below

Go to

Is this evidence suspicious of active TB?

Yes

Provide details below

Go to

Evidence of any other (non-TB-related) abnormalities?

Yes

Provide details below.

Section E

Radiologist’s declaration

This declaration must be signed and dated by the radiologist who examined the chest X-ray.

I certify that the statements made by me in answer to all the questions are true to the best of my knowledge and belief.

Signature of radiologist

Date

Radiologist’s details

(please print)

Full name

MCNZ number for New Zealand practitioners

Place of examination (city/state and country)

Postal address

Daytime telephone number

Email address

4 – X-Ray Certificate for Temporary Entry

X-Ray Certificate For Temporary Entry (Inz 1096) Page 4