TB Skin Test & Results Form
PROVIDER: Betty 'Laurie' Ryba, NP
TB Skin Test Directions:
Locate and clean injection site to 4 inches below elbow joint
Place forearm palm side up on a firm, well-lit surface
Select an area free of barriers to placing and reading (e.g., scars, sores)
Clean the area with an alcohol swab
A doctor will inject a tiny amount of tuberculin under the skin, usually in the forearm
A small, pale bump will form at the injection site
The second stage of diagnosis must take place between 48-72 hours after the tuberculin injection
Date of Test
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Patient Name:
*
Please Select
Jenny Martin
Cori Marzoni
Laurie Ryba
Emily Robertson
Other
Name (Other)
Brand of TB (PPD) Test:
*
Site of TB Placement:
*
Please Select
Left
Right
Lot#
*
Exp. Date
-
Month
-
Day
Year
Date
Test Admin by:
*
Please Select
Jenny Martin
Cori Marzoni
Laurie Ryba
Emily Robertson
Induration
please note in mm
Result:
Please Select
Pending
Negative
Positive
Date Test Read
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Read by:
Other
B Laurie Ryba, NP
Jenny Martin, RN
Cori Marzoni, RN
Chest X-Ray Needed
Please Select
No
Yes
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