TB Skin Test One-Step Protocol

Tuberculin Skin Testing
First Name*
MI
Last Name*
Date of Birth*

MonthDayYear
Date
Age*
Gender*
Best Phone Number*
Please enter a valid phone number.
Address*

Home Address

Street Address Line 2

CityState

Zip
Primary Care Provider
Is this test a requirement for an organization or clinic?*

YesNo
If yes, what is the name of the organization or clinic?
Please answer the following exclusion criteria questions:
Do you have an allergy to any component of the TST or had a previous reaction to TST?*

YesNo
Do you have a history of severe reaction (necrosis, blistering, anaphylactic shock, or ulcerations) to a previous TST?*

YesNo
Do you have documented active TB or a clear history of treatment for TB infection or disease?*

YesNo
Do you have extensive burns or eczema at the administration site?*

YesNo
Have you had a live vaccination administered within the last 28 days?*

YesNo
Do you have a history of a positive TST?*

YesNo
Do you have a history of documented previous bacilli Calmette-Guerin (BCG) vaccination?*

YesNo
·        I hereby authorize the pharmacists at Eastridge-Phelps Pharmacy/EP Medical to administer a Tuberculin Skin Test.

·          I agree that the results of this test may be shared with other health care providers.

·          I understand that this information will be used by health care providers for care and for surveillance /statistical purposes only.

·          this information will be kept confidential
Signature*

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IMPORTANT: A decision to test is a decision to treat. Given the high rates of false positive TB skin test results, the Kentucky TB Prevention and Control Program discourages administration of the Mantoux TST to persons who are at a low risk for TB infection.
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