Step Tb Form PDF Details

At the heart of health screening within educational settings for students pursuing healthcare-related fields at Westmoreland County Community College lies the Baseline Two-Step PPD (Mantoux) form, alongside its subsequent PPD documentation. This crucial paperwork facilitates the thorough and systematic process of Tuberculosis (TB) skin testing, ensuring prospective healthcare workers are screened for TB, a vital step in protecting both them and the patients they will eventually care for. The form mandates detailed information including the facility or physician’s office details, the student's name, date of birth, and specific results from PPD skin tests. It distinguishes between individuals who have previously had a positive PPD skin test—requiring a recent chest X-ray—and those new to the testing process or needing their annual check. Each stage, from administering the test to interpreting the results, is carefully documented, reinforcing the significance of accurate record-keeping in healthcare settings. Also, it underscores the necessity for a second test if the first is positive, to confirm TB exposure, proving the method's thoroughness and the college's commitment to high health standards.

QuestionAnswer
Form NameStep Tb Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesstep tb forms, step tb form, blank 2 step ppd form pdf, small blank ppd form

Form Preview Example

 

 

 

 

 

 

 

WESTMORELAND COUNTY COMMUNITY COLLEGE

 

 

 

 

 

 

 

BASELINE TWO-STEP PPD (MANTOUX)

Please Print Clearly:

 

 

 

 

 

 

 

 

 

Facility Name or Physician’s Office

 

 

 

 

 

 

Phone:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Facility or Physician’s Office Address:

 

 

 

 

 

 

 

 

 

 

Student Name:

 

 

 

 

 

Date:

 

D.O.B:

 

 

 

 

 

 

 

 

 

 

 

HAVE YOU PREVIOUSLY HAD A POSITIVE RESULT FROM A PPD SKIN TEST: YES

NO

(IF YES, A CHEST X-RAY WITHIN THE PAST 5 YEARS IS REQUIRED – ATTACH REPORT)

 

 

 

 

 

 

UNLESS DOCUMENTATION CAN BE PROVIDED TO INDICATE A NEGATIVE BASELINE TWO-STEP PPD WITHINTHE PAST TWELVE MONTHS,

A BASELINE TWO-STEP PPD IS REQUIRED.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#1 PPD skin test/annual PPD skin test given:

 

Site: Left:

Right

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Manufacturer:

 

 

Administered by:

 

 

 

 

 

 

 

 

Lot #:

 

 

(Full signature)

 

 

 

 

 

 

 

 

Expiration Date:

 

 

Date/time:

 

 

 

 

 

 

 

 

 

 

 

PPD READINGS: 48-72 HOURS AFTER ADMINISTRATION

 

 

 

 

 

 

M – T – W – TH – F – S (Circle day/s for reading)

 

 

 

 

 

 

PPD skin test result

 

mm induration

 

 

 

NOTE—Positive test: Must be referred to a physician since a full chest X-ray is required.

______________________________________________________________

 

Full Signature of PPD Reader

Date/time

 

 

 

 

 

#2 PPD skin test/annual PPD skin test given:

Site: Left:

Right

 

 

 

 

 

 

 

 

 

 

Manufacturer:

 

Administered by:

 

 

Lot #:

 

(Full signature)

 

 

Expiration Date:

 

Date/time:

 

 

PPD READINGS: 48-72 HOURS AFTER ADMINISTRATION

M – T – W – TH – F – S

(Circle day/s for reading)

PPD skin test result

 

 

mm induration

NOTE—Positive test: Must be referred to a physician since a full chest X-ray is required.

______________________________________________________________

Full Signature of PPD Reader

Date/time

Please return this form to: Becky Lauffer, RN, BSN

Coordinator, Emergency Medical Services and Health Care Continuing Education Programs Westmoreland County Community College

145 Pavilion Lane Youngwood, PA 15697-1895

Phone: (724) 925-4082 – FAX: (724) 925-4294

J:\coned\HEALTHCARE\emt/PPD

 

 

 

 

WESTMORELAND COUNTY COMMUNITY COLLEGE

 

 

 

 

SUBSEQUENT PPD

Please Print Clearly:

 

 

 

 

 

 

Facility Name or Physician’s Office

 

 

 

Phone:

 

 

 

 

 

 

 

 

 

 

 

Facility or Physician’s Office Address:

 

 

 

 

 

 

 

Student Name:

 

 

Date:

 

D.O.B:

 

 

 

 

 

 

 

 

HAVE YOU PREVIOUSLY HAD A POSITIVE RESULT FROM A PPD SKIN TEST: YES

NO

(IF YES, A CHEST X-RAY WITHIN THE PAST 5 YEARS IS REQUIRED – ATTACH REPORT)

 

 

 

 

 

 

IF YOU HAVE NOT PREVIOUSLY HAD A POSITIVE PPD SKIN TEST AND YOU CAN PROVIDE DOCUMENTATION OF A TWO-STEP PPD WITHIN THE PAST TWELVE MONTHS, THIS FORM CAN BE USED FOR A SUBSEQUENT ANNUAL PPD REPORT.

Please Note: You must also submit the Baseline Two-Step PPD results on the Baseline Two-Step PPD form.

Annual PPD skin test given:

Site: Left:

Right

 

 

 

 

 

 

 

 

 

 

Manufacturer:

 

Administered by:

 

 

Lot #:

 

(Full signature)

 

 

Expiration Date:

 

Date/time:

 

 

PPD READINGS: 48-72 HOURS AFTER ADMINISTRATION

M – T – W – TH – F – S

(Circle day/s for reading)

PPD skin test result

 

 

mm induration

NOTE—Positive test: Must be referred to a physician since a full chest X-ray is required.

______________________________________________________________

Full Signature of PPD Reader

Date/time

 

 

Please return this form to:

Becky Lauffer, RN, BSN

 

Coordinator, Emergency Medical Services and Health Care Continuing Education Programs

 

Westmoreland County Community College

 

145 Pavilion Lane

 

Youngwood, PA 15697-1895

 

Phone: (724) 925-4082 – FAX: (724) 925-4294

J:\coned\HEALTHCARE\emt/PPD

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2. Once your current task is complete, take the next step – fill out all of these fields - Full Signature of PPD Reader, PPD skin testannual PPD skin test, Site Left, Right, Administered by Full signature, PPD READINGS HOURS AFTER, M T W TH F S Circle days for, PPD skin test result, mm induration, NOTEPositive test Must be referred, Full Signature of PPD Reader, and Please return this form to Becky with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

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It's easy to make errors while completing the Please return this form to Becky, hence be sure to reread it prior to deciding to submit it.

3. In this step, check out Please Print Clearly Facility Name, Phone, Date, Annual PPD skin test given, Site Left, Right, Administered by Full signature, PPD READINGS HOURS AFTER, M T W TH F S Circle days for, PPD skin test result, and mm induration. All of these have to be taken care of with greatest focus on detail.

Step # 3 for filling in blank tb 2 step form

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