Mantoux Tuberculin Skin Test Record Form at a glance
What it is: Mantoux Tuberculin Skin Test Record Form of the Raritna Bay Medical Center Volunteer Services Department.
Who signs: The Reader signs on the Signature line, after Name of Reader.
A filled-in Mantoux Tuberculin Skin Test Record Form example: a volunteer records a first skin test
How to fill out Mantoux Tuberculin Skin Test Record Form, box by box
Patient Information
Under Patient Information, fill in Name, Address, City/Town, State, Zip and Telephone, with a Home number and a Work number.
Skin Test Information
Under Skin Test Information, fill in Administrator Name, Date/time Administered, Arm on which Administered, Manufacturer of PPD Solution, Expiration Date of PPD Solution and Lot #.
Results
Under Results, fill in Induration in mm, Date/time of Reading, Comments and Adverse Reaction(s), if any*, and Name of Reader.
Signature
The Reader signs on the Signature line, after Name of Reader.
More rules for Mantoux Tuberculin Skin Test Record Form
New Jersey State regulations require that all new volunteers have a two-step Mantoux tuberculin skin test (2 injections, 2 weeks apart) before they are assigned to a volunteer position in the medical center.
On the Raritna Bay Medical Center form, the * on Adverse Reaction(s), if any: It is very unlikely that a side effect to the test will occur. If such an event does happen, the most common reaction is pain or redness at the test site.
On the Raritna Bay Medical Center form, the * on Adverse Reaction(s), if any: In very rare cases, a person who is hypersensitive to the solution could have a severe allergic reaction near the injection site. Such rare reactions may include blistering or a skin wound.
Sources
[1] Mantoux Tuberculin Skin Test Record Form, Raritna Bay Medical Center Volunteer Services Department (the Official source link on this page).