Initial Two-Step Tuberculin Skin Test Report Form
College of Saint Benedict/Saint John’s University – Department of Nursing
The deadline for submission is August 15. Please email a scanned copy to dbaloun@csbsju.edu and keep a copy for your records.
Student Information (please print)
________________________________________ |
______________________________ |
Last Name |
First |
Clinic Information
________________________________________ |
______________________________ |
____________________ |
Clinic Name |
City, State |
Phone |
PLEASE NOTE: If the student has recently traveled to a TB high-risk area, he/she must complete a TB Symptom Screening Form by August 15. The two-step PPD and this form can then be completed 8-10 weeks after returning to the U.S.
Two-step PPD (Mantoux)
NOTE: QuantiFERON blood test, tine, or monovac are not acceptable.
STEP 1:
Date Given: _______________ |
Signature/Title: ___________________________________ |
Date Read: ________________ |
Signature/Title: ___________________________________ |
Step 1 Results: _____mm |
Interpretation: Negative |
Positive |
* Results must be read within 48-72 hours by trained personnel. |
STEP 2: |
|
|
|
Date Given: _______________ |
Signature/Title: ___________________________________ |
Date Read: ________________ |
Signature/Title: ___________________________________ |
Step 2 Results: _____mm |
Interpretation: Negative |
Positive |
*Results must be read within 48-72 hours by trained personnel.
Previous or current positive PPD or received BCG
A chest x-ray is required within two years and screened for absence of active TB symptoms.
Chest x-ray date: __________________ Results: Negative Positive
Medical Treatment Plan: ____________________________________________________
Student can cannot participate in providing patient care in all clinical areas.
Provider Signature/Title: __________________________________________________
This information is strictly CONFIDENTIAL and is used to comply with contractual requirements of clinical agencies. Information supplied will become a part of your health record; it will not influence your standing at the college, and it will not be released to anyone except by your written authorization.
