SC DHEC Form 1420 PDF Details

The SC DHEC 1420 form plays a pivotal role in the health and safety protocols of educational and childcare facilities in South Carolina. Anchored in the state’s efforts to combat the spread of tuberculosis (TB), this specific document is designed to meticulously track and document TB evaluations for individuals employed within (or in the process of being employed by) public or private schools, kindergartens, nurseries, or day care centers. A comprehensive certificate, it encompasses fields for personal information, employment details, and crucially, the results of TB skin tests or chest X-rays. Moreover, it outlines the steps taken if TB infection is detected, including prevention treatments started or completed, and certifies whether an individual poses no risk of TB transmission, hence can safely engage in employment. The form serves as a testament to the individual's TB status, conforming to the stringent guidelines approved by the South Carolina Department of Health and Environmental Control (DHEC) as per the Code of Laws of South Carolina. Ensuring compliance and the safety of both staff and the children in their care, the DHEC 1420 form is a vital instrument in the state’s public health arsenal, underscoring a commitment to preventing the spread of tuberculosis in environments critical to the community's welfare.

QuestionAnswer
Form NameSC DHEC Form 1420
Form Length2 pages
Fillable?Yes
Fillable fields63
Avg. time to fill out13 min 10 sec
Other namesdhec tb form, scdhec form 1420 in south carolina, sc dhec tb risk assessment form, dhec form 1420

Form Preview Example

DHEC 1420 (08/1998)

D H E C

Promote Project Prosper

School Employee/Individual Certificate of Evaluation for Tuberculosis

Name: Last

First

M.I.

Residence Address

City

County

 

 

 

 

 

Public or private school, kindergarten, nursery or day care center

Date Employed

 

 

of current employment

or other employer or individual

 

 

 

 

 

TEST RESULTS

DISPOSITION

CERTIFICATION

TUBERCULIN SKIN TEST _______

 

 

CHEST X-RAY

REMARKS

Date Given

 

 

Date:

 

 

 

 

 

5 TU PPD MANTOUX METHOD

 

 

 

 

 

Interpretation:

 

_____________mm __________________

 

 

 

 

Date Interpreted

 

 

 

 

_____ No tuberculosis infection per 5 TU

 

PPD1

 

 

 

_____ Tuberculosis infection, no evidence of disease

–––––Prevention treatment started _________________ and completed __________________________ 1

–––––Prevention treatment started _________________ but not completed __________________________ 2

–––––Prevention treatment not prescribed/refused 2

_____ History of tuberculosis disease Treatment started ________________ and completed

__________________ 1

_____ Current tuberculosis disease

––––– Non contagious as of _______________ and medically cleared to start/resume school

 

other employment on _____________________________ 2

 

 

1 No further routine screening required

2Remains at lifelong risk of developing tuberculosis

_____

This is to certify that I have examined the school employee named herein for tuberculosis and report my

finding as indicated above pursuant to the Code of Laws of South Carolina, 1976, as amended April 24, 1979

_____

This is to certify that I have examined the individual named herein for tuberculosis and report my findings as

indicated above.

 

 

 

 

 

Physician’s Signature

 

Date

DHEC 1420 (08/1998) DISPOSITION: This form shall be retained in the files of the current employer or individual following evaluation and certification.

SCHOOL EMPLOYEE/INDIVIDUAL CERTIFICATE OF EVALUATION FOR TUBERCULOSIS: this form may be used for school employees or other individuals who need documentation of tuberculosis evaluation. It should be maintained in the current employer’s file for school employees and by employer or individual for other needs.

CODE OF LAWS OF SOUTH CAROLINA, 1976, AS AMENDED APRIL 1979, SECTION 44-29-150. No person will be initially hired to work in any public or private school, kindergarten, nursery or day care center for infants and children until appropriately evaluated for tuberculosis according to guidelines approved by the south Carolina department of Health and Environmental Control. Reevaluation will not be required for employment in consecutive years unless otherwise indicated by such guidelines.

SECTION 44-29-160. Any person applying for a position in any of the public or private schools, kindergartens, nurseries, or day care centers for infants and children of the State shall, as a prerequisite to employment, secure a health certificate from a licensed physician certifying that such person does not have tuberculosis in an active state.

SECTION 44-29-170. the physician shall make the aforesaid certificate on a form supplied by the Department of Health and Environmental control, whose duty it shall be to provide such forms upon request of the applicant.

SUMMARY OF GUIDELINES OF THE DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL. (Regulation 61-22) Each employee shall have, prior to employment, and unless so previously tested, as a condition for further employment, a tuberculin skin test performed by intradermal injection of 5 tuberculin units of purified protein derivative of tuberculin (Mantoux test with 5 TU of PPD). Employees with test reactions measuring lest than 10mm or more shall have a chest x-ray, shall be recorded on the DHEC for 1420 which shall be kept in the files of the school principal/designee. These forms shall be subject to review by DHEC. If the chest x-ray (and examination of sputum, if necessary) shows evidence of current tuberculosis disease, the employee shall not be allowed to work until she/she receives written certification for DHEC that he/she is not contagious. Employees whose skin text reactions measure 10mm or more and who have a normal chest x-ray shall be evaluated for preventive therapy for their tuberculous infection. If preventive therapy is not prescribed, or is prescribed, but refused, a notation shall be made on the employee’s certificate that he/she is considered to be infected with tubercle bacilli and remains at lifelong risk, of developing tuberculosis disease. Testing other than the described above, shall be required only if there is epidemiological evidence that employees, attendees, or students in the school, nursery, day care center, or kindergarten have become infected with tuberculosis.

5

SC DHEC Form 1420 isn’t the one you’re looking for?

Related Documents