2 Step Tb Test Form Details

Most people are familiar with the Mantoux skin test, which is a common tuberculosis (TB) screening test. However, many don't know that there is a 2 step Mantoux form. This form requires two separate injections in order to get an accurate reading. In this blog post, we will discuss the 2 step Mantoux form and how it is used to screen for TB.

You will discover information regarding the type of form you want to prepare in the table. It can tell you the length of time you'll need to complete 2 step mantoux form, exactly what parts you will need to fill in, etc.

QuestionAnswer
Form Name2 Step Mantoux Form
Form Length2 pages
Fillable?Yes
Fillable fields28
Avg. time to fill out6 min 10 sec
Other namesprintable 2 step tb skin test form, generic 2 step tb skin test form, two step ppd form, 2 step ppd form

Form Preview Example

GROSSMONT COLLEGE HEALTH PROFESSIONS

MANTOUX TUBERCULIN SKIN TEST REQUIREMENTS

NAME:

LAST

FIRST

GCCCD STUDENT ID#:

All Health Profession students are required to have a 2-step INTRADERMAL TST (MANTOUX) prior to program start, unless previously positive. A TB test or Questionnaire is due yearly for all students. See the following page for more information.

If positive, to be cleared for the Nursing Program, supporting documentation of a positive TB result must accompany this form for any TB test previously completed. The size of indurations must be measured in mm and a copy of a clear chest x-ray is required to be on file in the program office.

On this form, a signature and stamp will only be accepted from the following: Physician, Physician Assistant, Nurse Practitioner, Registered Nurse, or Grossmont College Health Services Nurse.

Step #1

 

Date: _______________

Manufacturer: ______________________________ Dose: 0.1mL

 

 

 

Time Given: __________

Exp. Date: __________________

Lot#: __________________

 

 

 

 

Given By: _____________________________________________

 

 

 

 

 

signature

 

 

 

 

 

Date: _______________

Results: ___________mm

 

 

 

 

 

Time Read: __________

Read By:______________________________________________

 

 

 

 

 

signature

 

 

 

 

 

 

 

 

 

 

 

 

 

If Mantoux Positive:

Results:

Negative

Positive

 

 

 

Chest X-Ray Required

 

 

 

 

 

 

 

Date: _______________

(a copy of the report must be submitted with this form to the Program office)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Step #2 (No sooner than 7 days after Step #1)

 

 

 

Date: _______________

Manufacturer: ______________________________ Dose: 0.1mL

 

 

 

 

Time Given: __________

Exp. Date: __________________

Lot#: __________________

 

 

 

 

 

Given By: _____________________________________________

 

 

 

 

 

 

signature

 

 

 

 

 

Date: _______________

Results: ___________mm

 

 

 

 

 

Time Read: __________

Read By:______________________________________________

 

 

 

 

 

 

signature

 

 

 

 

 

 

 

 

 

 

 

 

 

If Mantoux Positive:

Results:

Negative

Positive

 

 

 

 

Chest X-Ray Required

 

 

 

 

 

 

 

Date: _______________

(a copy of the report must be submitted with this form to the Program office)

 

 

 

 

 

 

 

 

 

 

 

GROSSMONT COLLEGE HEALTH PROFESSIONS

MANTOUX TUBERCULIN SKIN TEST INFORMATION

If you have never had a TB test OR if it has been over 12 months since receiving your last negative TB test;

1.A baseline “Two-Step” Mantoux Test (PPD) is required for all new students regardless of prior

BCG inoculation.

2.After baseline testing, all health care students must have an annual Mantoux Test. If the interval between testing is greater than 364 days, the Two-Step will be repeated.

If you have a documented negative TB test within 12 months of entering the program;

1.A “One-Step” is required ONLY if a negative Mantoux test result is documented within the previous 12 months. Date done and proof of this past testing is required. Prior “Two-Step” baseline testing will be accepted only if done no more than 3 months prior to enrollment.

2.After baseline testing, all health care students must have an annual Mantoux Test. If the interval between testing is greater than 12 months, the Two-Step will be repeated.

If you do NOT have documentation for a negative TB test done within 12 months of entering the program;

1.A repeat baseline Two-Step” Mantoux Test (PPD) is required. There is no danger in having these tests repeated. This is if documentation is not available to you.

2.After baseline testing, all health care students must have an annual Mantoux Test. If the interval between testing is greater than 12 months, the Two-Step will be repeated

If you have previously had a positive Mantoux (PPD) test;

1.All new students with a previously positive Mantoux must provide the following documentation:

1)the reported induration measured in mm and 2) one chest radiograph to exclude a diagnosis of

TB disease. After this baseline chest radiograph is performed and the result is documented, repeat radiographs are not needed unless symptoms or signs of TB disease develop or a clinician

recommends a repeat chest radiograph OR 3) have a BAMT (blood assay for M. tuberculosis). If the

latter, proof of testing with a complete report which provides an interpretation of the test result and indicates the concentration of interferon-gamma. If the BAMT results are “inconclusive” or “positive”,

a report of a negative chest x-ray is to be provided.

2.Students with a previously positive Mantoux must have an annual symptom check and evaluation in the Student Health Service.

Mantoux Conversion

1.If a test result becomes positive (induration > 10mm) after previously being negative, neither student nor faculty may be on campus or attend class until cleared by a negative chest x-ray report is submitted to the Grossmont Student Health Service.

2.Medical evaluation for possible treatment of LTBI is recommended for those individuals with a known recent Mantoux conversion.

REV.02/2013 CG

How to Edit 2 Step Mantoux Form

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example of fields in ppd 2 step forms

In the If Mantoux Positive: Chest X-Ray, Date: , (a copy of the report must be, Step #2 (No sooner than 7 days, Date: , Manufacturer: Dose: 0, Time Given: , Exp, Given By: signature, Date: , Results: mm, Time Read: , If Mantoux Positive: Chest X-Ray, Date: , and Read By: signature field, note down your data.

ppd 2 step forms If Mantoux Positive: Chest X-Ray, Date: , (a copy of the report must be, Step #2 (No sooner than 7 days, Date: , Manufacturer:  Dose: 0, Time Given: , Exp, Given By:  signature, Date: , Results: mm, Time Read: , If Mantoux Positive: Chest X-Ray, Date: , and Read By: signature blanks to fill out

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