Tb (Tuberculosis) Test Verification Form - 2015 printable pdf download

School of Nursing

3800 Victory Parkway

Cincinnati, OH 45207-7351

513 745-3814

TB (Tuberculosis) TEST VERIFICATION FORM

Page 1: Year 1 Clinical Pre-Licensure Students (BSN Sophomores & Year 1 MIDAS Students)

FNP Students: Refer to Page 2

STUDENT: COMPLETE THIS SECTION

I understand that in the first year of clinicals I must obtain and submit documentation of a negative two-step TB

test (given/read and 1-3 weeks later given/read again). Annually thereafter I must obtain and submit proof of

absence of tuberculosis. After year 1, the usual method of meeting this requirement is verification of a one-step

negative tuberculin skin test (two-step in first clinical year and one-step annually thereafter).

Alternately, verification of a negative QuantiFERON TB Gold blood test meets the TB test requirement. If a chest X-ray is

warranted, results of the chest X-ray followed by annual symptom checks are required.

Student signature __________________________________________________________________ Date ___________________

Student printed name _______________________________________________________________ DOB ___________________

HEALTH PROFESSIONAL: COMPLETE THIS SECTION

(or provide student with your facility’s verification which must include results)

Mantoux Skin Test #1 (THIS 2 STEP SERIES TB TEST IS ONLY REQUIRED IN YEAR 1 OF CLINICAL COURSES.)

Date Given ________________Given by ______________________________________________

Signature

Credentials

Date Read ________________ Read by _______________________________________________Result _____________ record as MM induration

Signature

Credentials

Mantoux Skin Test #2 (STEP #2 GIVEN 1-3 WEEKS AFTER STEP #1).

Date Given ________________Given by ______________________________________________

Signature

Credentials

Date Read ________________ Read by _______________________________________________Result _____________ record as MM induration

Signature

Credentials

NAME/ADDRESS/PHONE OF HEALTH CARE PROVIDER

_____________________________________________________

ALTERNATE FORMS OF VERIFICATION OF ABSENCE OF TB

Provide documentation of results of a negative blood test for TB

Provide documentation of a current negative TB test and a negative TB test within a year of the current one OR

Provide documentation of results of a negative chest X-ray (< 1 yr. old). Requirement for subsequent years, rather than

additional chest x-rays, is a Symptom Checklist completed by a medical professional verifying absence of TB symptoms.

NAME/ADDRESS/PHONE OF HEALTH CARE PROVIDER (if not on attached verification):

_____________________________________________________

Instructions for submission of documentation are at

TB_Form, 7/9/2015

Tb (Tuberculosis) Test Verification Form - 2015