I consent to a tuberculin skin test (TST) for the above reason(s) I understand I am to have the skin test read in 48-72 hours by . If testing for latent TB infection is required (and you have answered NO to all questions in Part A), you will still be able to commence placement.

The Mantoux tuberculin skin test should always be placed and read by a designated, trained health care worker . INSTRUCTIONS: HEALTH CARE PROVIDER - All Boxes Must Be Completely Filled In. Form Reviewed: Form Revised: 3/2/2016 . In your work site: • Slowly inject the tuberculin 6. Clinicians should review and verify the information in Part I.

UNIVERSITY HEALTH CENTER University of Georgia Athens, GA 30602-1755 Phone: 706-542-1162 Fax Nr: 706-542-4959 or 706-583-0777 NAME: UGA ID#: Date of Birth: PART II.

DATE. a Tuberculin Skin Test (TST/Mantoux test) can be performed by referral to a TB Control Unit – at no cost to the patient, but requires a follow-up appointment 2 or 3 days later. F. RISK FACTORS: (PLEASE CHECK ALL THAT APPLY) No Known Risk Factors Contact to TB Case High … the designated reader/interpreter. Form # Title: PDF/WORD: Instruction/ Comments: LAB-10: Request for Quantiferon-TB Gold Test In-Tube Method (QFT-IT) pdf 14k doc 49k TB-1: Quarterly Chest Clinic Activity Report: pdf 9k doc 31k TB-3: Medication Request Order (Updated March, 2016) pdf 14k …

CLIENT/GUARDIAN SIGNATURE . • Hold the skin test site taut • Position the needle, bevel up. CLINICAL ASSESSMENT BY HEALTHCARE PROVIDER. • Submit the completed form (Employee Tuberculin Skin Test (TST) and Evaluation, CDCR 7336), in a sealed envelope, as instructed by your supervisor/TB coordinator. VANDERBILT UNIVERSITY MEDICAL CENTER The Digestive Disease Center The Inflammatory Bowel Disease Clinic PPD Tuberculin Skin Test Patient Name DOB VUMC MRN On // you received a PPD tuberculin skin test Injection given by Right Arm Left Arm TB Skin tests MUST be read by a healthcare provider within 48-72 hours or the test will need to be repeated.

Insert intradermally at a 5° to 15° angle to the skin. Discuss skin test training, certification programs, and requirements in your locality . The needle tip should be visible just below the skin’s surface. In this video, you’ll learn how to test for TB infection by administering and reading the Mantoux tuberculin skin test. TB Skin Testing Form Name: _____ Program: _____ Home Phone #: _____ SECTION 1: TB SKIN TESTING HISTORY Date of last TB skin test: _____ Result: ____ __ mm of induration Note: Need to Submit copy of last TB.

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If given in VUMC clinic it must be … Lt. If I do not return in 48-72 hours, I understand that I may need to have the TST readministered .

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