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____________ |
