TWO STEP TUBERCULIN SKIN TEST FORM

For previous POSITIVE TUBERCULIN skin Test, complete the section at the bottom of page. TWO step TUBERCULIN skin TEST FORM. Print Name _____ Date of Birth _____. Signature _____ Date _____. TUBERCULIN skin TEST RECORD. TEST ONE: Manufacturer & Lot number _____Manuf. Exp. Date _____ Date vial opened _____. Date & time test applied _____ _____ AM PM Site of injection _____. Name & Title of person placing the skin test _____. Signature _____. (PPD readings must be 48 72 hours after administration.). Date & Time test read _____AM PM Induration _____mm Name & Title of person reading & interpreting the skin test _____. Signature _____. _____. TEST TWO: Given one to three weeks after Test One. Manufacturer & Lot number _____Manuf. Exp. Date _____ Date vial opened _____. Date & time test applied _____ _____ AM PM Site of injection _____. Name & Title of person placing the skin test _____. Signature _____. (PPD readings must be 48 72 hours after administration.)

For previous POSITIVE Tuberculin Skin Test, complete the section at the bottom of page. TWO STEP TUBERCULIN SKIN TEST FORM ... TB Screening Form – Please indicate if you have any of the following symptoms: Yes No Chronic Cough Yes No Unexplained weight loss Yes No Production of sputum Yes No Unexplained fatigue/tiredness ...

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  Tests, Step, Skin, Step two, Skin test

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