Fill In The Blanks On Tuberculosis PDF Details

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QuestionAnswer
Form NameFill In The Blanks On Tuberculosis
Form Length1 pages
Fillable?Yes
Fillable fields82
Avg. time to fill out16 min 39 sec
Other nameslouisiana tb screening form, tb test for employment form, tb test form for employment, employment printable tb skin test form template

Form Preview Example

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____________

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filling in annual fit testing short questionnaire stage 1

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annual fit testing short questionnaire PLACEDDateTimeAMPMLARAMFTLotExpDate, ByPrintNameTitleSignature, and ByPrintNameTitleSignature blanks to insert

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