PPD (MANTOUX) TUBERCULOSIS SKIN TEST
(Tine or Manovac is not acceptable)
PLEASE PRINT |
|
STUDENT INFORMATION
Completed by Student |
| Last Name______________________ |
First Name _______________________ |
MI ___ |
| Student ID (not SSN): _________________________________________ |
| Placement (Please select one) |
- Student Teaching _______
|
- Early Fields (Indicate course and number, ex EDUC205) ______________________ |
- Other (indicate course and number) __________________________ |
|
TEST RESULTS
Completed by Health Care Providor
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PLEASE COMPLETE ALL SECTIONS |
HEALTH CARE PROVIDER
The health care provider signing this form is asked to assist us by signing the top of his/her prescription form or official letterhead and attaching it to this form. |
| PPD (Mantoux) Test Result: _________________ Negative _______ Positive _______ |
| Induration (mm): ___________________________ (required) |
| Date administered: ______________________ |
| Date read: ____________________________ |
| Signature of Health Care Provider: __________________________________________ |
| Date ___________________ |
