Two Step Tb Test Form Template PDF Details

Tb is a serious issue that can impact people of all ages. If you are concerned that you may have tb, it is important to get tested as soon as possible. The two step tb test form template makes the process easy and convenient. Simply fill out the form and take it to your nearest clinic or hospital for testing. Getting tested is the best way to determine whether or not you have tb and to begin treatment if needed.

If you need to know a number of specific details pertaining to the file you'll use, here's the data you might like to study before filling out the two step tb test form template.

QuestionAnswer
Form NameTwo Step Tb Test Form Template
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other names2 step tb skin test form, 2 step tb test form, ppd forms, blank 2 step ppd form pdf

Form Preview Example

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.

Watch Two Step Tb Test Form Template Video Instruction

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .