Fill In The Blanks On Tuberculosis PDF Details

Understanding the importance and details of the Tuberculosis Skin Test (TST) Screening form is critical for individuals in environments where TB exposure is a risk. Located at 57 Bee Street, the Employee Health Services provides this essential screening service, catering to a broad spectrum of clients, including employees undergoing pre-placement evaluations, annual assessments, and those who have experienced exposure to tuberculosis. Additionally, this service is available to various affiliations such as MUHA (Hospital), Crothall, MUSC (University), Sodexho, and more, highlighting the form's comprehensive application across different sectors. The form meticulously collects personal information; employment details; past TB tests, if any; recent vaccinations; and the individual's current health status, particularly focusing on symptoms related to tuberculosis. Moreover, it emphasizes the responsibility of the individual to have the TST read by a licensed professional and to report the results back to the Employee Health Services, adhering to protocols set by health authorities like DHEC, OSHA, and JCAHO. The process includes two steps of testing to ensure accuracy, with guidelines on when and how the read results should be returned to the health services, showcasing the strict adherence to ensuring public and individual health safety. This comprehensive approach not only adheres to regulatory requirements but also underscores the shared responsibility between the individual and healthcare providers in managing TB risks.

QuestionAnswer
Form NameFill In The Blanks On Tuberculosis
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namestb screening form pdf, tb forms for work, tb test form for employment, annual fit testing short questionnaire

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EMPLOYEE HEALTH SERVICES

57 Bee Street – MSC 213

Charleston, SC 29425-2130

TUBERCULOSIS SKIN TEST (TST) SCREENING

Telephone

(843) 792-2991

 

Fax

(843) 792-1200

 

REASON:

 

EMPLOYER:

 

฀ Pre-Placement

฀ 1st Step ฀ 2nd Step

฀ MUHA (Hospital)

฀ Crothall

฀ Annual

 

฀ MUSC (University)

฀ Sodexho

฀ Annual Past Positive Screening

฀ UMA/CFC

฀ Other________________

฀ Exposure Baseline (with ACORD)

฀ Volunteer

 

฀Post Exposure (10 week with ACORD)

Last Name____________________ First_______________ MI____ Birth date____/____/____ Emp ID_______________

Dept___________________ Position____________________ Work #_________________ Home #_________________

Address______________________________________ City____________________ State_____ Zip Code___________

Have you ever had a positive TST? ฀ YES ฀ NO If yes, when?________________________________________

Have you received a live vaccine within the past 30 days? ฀ YES ฀ NO

If yes, what vaccine? ฀ Measles, Mumps, Rubella (MMR) ฀ Varicella (Chickenpox) ฀ Other___________________

Are you immune compromised or are you taking any immunosuppressant medications? ฀ YES ฀ NO

Do you currently have any of the following chronic conditions?

YES / NO

YES / NO

YES / NO

฀

฀ Chronic cough (>3 weeks)

฀

฀ Cough up sputum or blood

฀

฀ Poor appetite

฀

฀ Chronic fatigue (>3 weeks)

฀

฀ Shortness of breath

฀

฀ Recurrent infections

฀

฀ Chronic chest discomfort

฀

฀ Unexpected weight loss

 

 

฀

฀ Persistent low grade fever

฀

฀ Night Sweats (excluding menopause)

 

Annual TST is performed to meet DHEC, OSHA, and JCAHO requirements.

•It is YOUR responsibility to have your TST read by a licensed person (MD, RN, LPN, RT) within 48-72 hours and return proof to EHS. You may not read your own TST.

•Your TST may show erythema (flat redness) or induration (hardened, raised area). If your skin test shows induration, it must be read by Employee Health Services.

I have read and understand the above instructions. I also understand that I will be given one copy of this form free of charge; hereafter there will be a charge for copies. I understand that I am advised to keep a copy of this form to avoid future charges.

Signature________________________________________________________________ Date____________________

LICENSED PERSONNEL PLEASE COMPLETE THIS SECTION

PLACED: Date__________ Time__________AM / PM LA / RA MFT/Lot #__________ Exp Date__________

By (Print Name)_________________________ (Title)__________ (Signature)___________________________________

(DO NOT cover injection site with band-aid or adhesive tape as some employees may have a reaction to the adhesive.)

READ: Date____________

Time__________AM / PM Results: Induration _______mm Erythema _______mm

By (Print Name)_________________________ (Title)__________ (Signature)___________________________________

Return to EHS for 2nd Step TST:

฀ Within 7-30 days ฀ After 30 days ฀ Not applicable

 

฀ Copy given to Employee, Date____________

How to Edit Fill In The Blanks On Tuberculosis Online for Free

Our PDF editor was created to be as straightforward as it can be. Since you follow these steps, the process of filling in the tb form for work document is going to be effortless.

Step 1: First of all, pick the orange "Get form now" button.

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All of the following sections are what you will need to prepare to get the prepared PDF file.

filling in printable tb test form for employment stage 1

Type in the requested particulars in the segment I have read and understand the, Signature Date, LICENSED PERSONNEL PLEASE COMPLETE, PLACED Date TimeAM PM LA RA, By Print Name Title Signature, DO NOT cover injection site with, READ Date TimeAM PM Results, By Print Name Title Signature, Return to EHS for nd Step TST, and Copy given to Employee Date.

printable tb test form for employment I have read and understand the, Signature Date, LICENSED PERSONNEL PLEASE COMPLETE, PLACED Date TimeAM PM LA RA, By Print Name Title Signature, DO NOT cover injection site with, READ Date TimeAM PM Results, By Print Name Title Signature, Return to EHS for nd Step TST, and Copy given to Employee Date blanks to insert

Step 3: As you hit the Done button, your prepared file can be exported to any of your gadgets or to email chosen by you.

Step 4: Make sure to prevent possible future worries by having a minimum of a couple of duplicates of your form.

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