In an effort to ensure the health and safety of its educational environment, the Los Angeles Unified School District (LAUSD) mandates that all permanent employees comply with its Tuberculosis (TB) Compliance Program, facilitated by the Human Resources Division's Employee Health Services Unit. Located at 333 S. Beaudry Ave., 14th Floor, Los Angeles, CA 90017, the unit oversees the TB Test Result Form, also known as the LAUSD HR Form 8472, a critical document that consolidates TB testing results. Employees have the flexibility to undergo TB testing either through their personal healthcare providers, at local county health departments (specifically for uninsured employees), or via other prescribed channels, albeit Employee Health Services no longer offers Mantoux skin tests or chest x-rays. The form meticulously outlines the prerequisites for test documentation, including a negative Mantoux skin test or chest x-ray result within the last three years, with specific instructions for cases of previously positive skin tests. The form emphasizes the necessity of submitting complete and valid documentation, bearing the employee’s number and precise test result information, to avoid rejection. Additionally, it underlines that neither the Mantoux skin test nor chest x-ray should be performed during work or duty hours, allowing the usage of illness time for such medical appointments if needed. Instructions for submitting the form, along with contact information for confirmation of receipt, are clearly provided to aid in compliance. This measure underscores LAUSD's commitment to maintaining a TB-free environment for its staff and students.
| Question | Answer |
|---|---|
| Form Name | Lausd Hr Form 8472 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | lausd tb risk assessment form, lausd tb compliance, E-mail, employeehealthlausd |
LOS ANGELES UNIFIED SCHOOL DISTRICT
HUMAN RESOURCES DIVISION – EMPLOYEE HEALTH SERVICES UNIT
Tuberculosis Compliance Program
333 S. Beaudry Ave., 14th Floor, Los Angeles, CA 90017
Phone: (213)
Tuberculosis Test Result Form
(For Permanent LAUSD Employees)
You can have the test performed by:
̇Your personal health care provider
̇Your local county health department (uninsured employees only)
For L.A. County residents, visit publichealth.lacounty.gov/tb/skintest.htm for a list of clinics and community health centers.
̇Employee Health Services (Beaudry Bldg.) no longer provide Mantoux skin tests or chest
IMPORTANT NOTES – READ CAREFULLY:
1.You may submit evidence of a negative Mantoux skin test or chest
2.Chest
3.We suggest you use the result form below. If you submit a different result form, it must include your employee number and all information required below for the specific test.
4.We will not accept incomplete/invalid documentation. Make sure your documentation has the required information.
5.Neither test shall be performed on work/duty time. If necessary, you may use illness time as you would for any medical related appointment.
Emp#:
Name:
Phone:
MANTOUX SKIN TEST |
CHEST |
(5 TU PPD required. Tine skin test unacceptable.) |
Positive Skin Test Date (estimate)_________________ |
Test Date ____________________________________ |
Date |
Placed By ____________________________________ |
Impression (Not Prelim.) ________________________ |
Date Read ___________________________________ |
Person is free of communicable TB: Yes No |
Read By _____________________________________ |
Physician’s Name _____________________________ |
Induration ________ Millimeters (>9mm is positive) |
Physician’s Degree (must be MD or DO) ___________ |
MEDICAL OFFICE CONTACT INFO: |
Physician’s Signature __________________________ |
|
|
Name ______________________________________ |
MEDICAL OFFICE CONTACT INFO: |
Address _____________________________________ |
Name _______________________________________ |
_____________________________________ |
Address _____________________________________ |
Phone ______________________________________ |
_____________________________________ |
|
Phone ______________________________________ |
|
|
Submit Your Result Form Via:
Fax: (213)
Attn. TB Compliance
School Employee Health Services
Mail: Attn. TB Compliance
Beaudry Bldg., 14th Floor
U.S. Employee Health Svcs (14th FL)
Mail: Attn. TB Compliance
P.O. Box 3307
Los Angeles, CA 90051
To Confirm Compliance:
If you want to confirm our office received your result form, send an
employeehealth@lausd.net
Subject: TB Confirmation - Emp# xxxxxx
*** Keep a copy of your result form for your records ***
LAUSD/HR FORM 8472 01/2011