School Volunteer Application Form - Volunteer Code Of Conduct Page 2
ADVERTISEMENT
1
2
3Attachment # 2
National School District Office/1500 “N” Ave., National City, CA 91950
TUBERCULOSIS SKIN TESTING
Name: ______________________________
Date of Birth / Age: ________________/__________
Phone Number: _______________________
Country of Birth: ____________________________
National School District Employee: YES_____
NO_____
………………………………………………………………………………………………..
CONSENT
Complete this Section
1. Have you ever had a positive TB skin test?
YES_______ NO_______
2. Have you ever taken medicine for a positive TB skin test?
YES_______ NO_______
3. Have you had a live virus vaccine within the past month?
YES_______ NO_______
(For example: oral polio, measles, chicken pox…)
4. Have you been in close contact with someone
who has had active TB in the past?
YES_______ NO_______
5. Do you consider yourself to be at high risk for HIV infection?
YES_______ NO_______
6. Are you 55 years of age or older?
YES_______ NO_______
IF YES, have you had a TB skin test in the last five years?
YES_______ NO_______
I request and authorize the staff of the National City Collaborative; National School District to evaluate
and/or provide a PPD Mantoux Tuberculin Skin Test. Questions about the test have been answered to
my satisfaction. I understand that the test is not complete until it has been read. I understand that the test
may include a medical referral to my medical provider and/or the San Diego County Public Health
Department.
______________________________________________
_______________________________
Signature
Date
………………………………………………………………………………………………………………..
Nurse to Complete
Administered PPD 5TU 0.1 ml Intradermal
Manufacturer: _______________________
Lot #: _____________________________
Site:
Left Forearm
Right Forearm
Expiration date: ______________________
Date given: __________________________ Nurse’s Signature: ___________________________
Date read: ___________________________ Results: Induration in mm: __________________
Interpretation:
____Negative
____Positive
Stamp: Clinic/Physician
Address
Read by - Nurse’s Signature: _______________________________
Phone
X-Ray indicated: ____YES ____NO
Referred to: _______________________________
If the TB test is completed by someone other that the District Nurse, form must include
Physician/Clinic stamp. Forms will not be accepted without stamp.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business