Form MO 580-1589 at a glance
What it is: MO 580-1589 is the Missouri Department of Health and Senior Services Tuberculosis Testing Record.
Where and when to file: Send the form to your local health department.
A filled-in Form MO 580-1589 example: a skin test for a new job
How to fill out Form MO 580-1589, box by box
A. PATIENT INFORMATION
Under A. PATIENT INFORMATION, enter the Name (last, first, middle initial), Date of Birth, Sex, Weight (lbs), Area Code and Phone Number, Country of Birth, Date Entered USA and Alien Number.
Enter the Street Address, City, County, Zip Code, Occupation, Place of Employment, Date of HIV Test and Results.
Under Race, mark White, Black, Asian/Pacific Islander, American Indian/Alaskan Native, Other or Unknown. Under Ethnic Origin, mark Hispanic or Non-Hispanic.
B. HISTORY OF TUBERCULIN TEST
Under B. HISTORY OF TUBERCULIN TEST, mark Have you ever had a BCG vaccine? No, Yes or Unknown and enter the Date of BCG Vaccine. Mark Have you ever had a tuberculin test? Yes, No or Unknown.
Enter the Date of Previous Skin Test and the Results of Previous Skin Test (mm).
C. CURRENT TUBERCULIN PPD MANTOUX TEST(S), IGRA AND X-RAYS
Under C. CURRENT TUBERCULIN PPD MANTOUX TEST(S), IGRA AND X-RAYS, mark Had live vaccinations in last four weeks? No or Yes. If yes, hold TST for four weeks.
Mark IGRA Test Done No or Yes. Enter the Date, and mark the Results Positive, Negative, Borderline or Indeterminate.
Enter the Date/Time PPD Administered, Manufacturer and Lot Number, then the Administrator's Signature. Enter the Date/Time Read, the Results and the Reader's Signature.
Mark Chest X-Ray Done No or Yes. Enter the Date Done, mark the Results Normal or Abnormal and enter the Findings.
D. HEALTH CARE PROVIDER
Under D. Health Care Provider, enter the Name/Facility, Address and Phone Number, Reported By, and the Date of Report.
E. REASON FOR TESTING
Under E. REASON FOR TESTING, mark Contact to TB Case, Employment, Medically Referred, Symptomatic, Immigration, Insurance, Educational Enrollment, Resident or Other. Under Employer/Residence, mark Long term Care Facility, Department of Corrections, Health Care Facility, Substance Abuse Center, School/Day Care, County Jail or Other.
Sign on CLIENT/GUARDIAN SIGNATURE and enter the Date. The consent: I consent to a tuberculin skin test (TST) for the reason(s) marked under E. REASON FOR TESTING. I understand I am to have the skin test read in 48-72 hours by the designated reader/interpreter. If I do not return in 48-72 hours, I understand that I may need to have the TST readministered.
Common questions about Form MO 580-1589
Where do I file it?
Send the form to your local health department.
Sources
[1] Form MO 580-1589 (12-19), Tuberculosis Testing Record, Missouri Department of Health and Senior Services (the Official source link on this page).