2 Step Mantoux Form – Fill Out and Use This PDF

GROSSMONT COLLEGE HEALTH PROFESSIONS

MANTOUX TUBERCULIN SKIN TEST REQUIREMENTS

NAME:

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

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