Tb (Tuberculosis) Test Verification Form - 2015 (Page 2 of 2) in pdf

School of Nursing

3800 Victory Parkway

Cincinnati, OH 45207-7351

513 745-3814

TB (Tuberculosis) TEST VERIFICATION FORM

Page 2: BSN Juniors, BSN Seniors, Year 2 MIDAS Students and FNP students

STUDENT: COMPLETE THIS SECTION

I understand that annually I must obtain and submit proof of absence of tuberculosis. The usual method of meeting

this requirement is verification of negative tuberculin skin testing. Alternately, submission annually of negative results

of a blood test for TB meets this requirement. If a chest X-ray is warranted, results of the chest X-ray followed by annual

symptom checks are required. The TB Symptom Check form is available at

If my health status changes, I will inform the School of Nursing (SON) and my instructor to avoid putting my health and academic status at

risk. It is my responsibility to maintain copies (future employers, etc. may require records).

Student signature __________________________________________________________________ Date ___________________

Student printed name _______________________________________________________________ DOB ___________________

HEALTH PROFESSIONAL: COMPLETE THIS SECTION

Mantoux Skin Test (THE 1 STEP TB TEST IS REQUIRED IN YEAR 2 OF CLINICAL COURSES.)

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 results of a negative blood test for TB

Provide (if Year 1 verification was a chest x-ray), a Symptom Checklist completed by a health professional

verifying absence of TB symptoms (form at ).

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 Page 2