Skin Test

Skin Test
Step #1   Type a label    was given a Mantoux tuberculin ppd intradermal skin test by   Type a label   on   Type a label   on left/right forearm.
Lot#   Type a label   Brand   Type a label   Expiration   Type a label   Results   Type a label   mm induration Date   Type a label   Read by   Type a label

Step #2 by   Type a label   on   Type a label   on left/right forearm. Lot#   Type a label   Brand   Type a label   Expiration   Type a label   Results   Type a label   mm induration Date   Type a label   Read by   Type a label
Note: Do not include redness or ulceration reading your results. Read results across (transverse) forearm. See TB protocol for classification of results.

If a skin test is > 10mm and has one or more risk factors for infection, the employee should be referred to the county health department or a local physician for follow-up assessment.
Name

First NameLast Name
Signature

Powered by Jotform SignClear
Date

MonthDayYear
Date
Should be Empty: