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Guide for Primary Health Care Providers: Targeted Tuberculin Testing and Treatment of Latent Tuberculosis Infection 2005Appendix DSample TST and Treatment Documentation FormsTuberculin Skin Test RecordTo Whom It May Concern: The following is a record of Mantoux tuberculin skin testing: Name: Date of birth: Date and time test administered: Administered by: Manufacturer of PPD: Expiration date: Lot Number: Date and time test read: Date:_________ Results (in millimeters of induration): Treatment Completion LetterTo Whom It May Concern: The following is a record of evaluation and treatment for M. tuberculosis infection: Name:______________________________ Date of birth: __________________ TST: Date:_____ Chest radiograph: Date: Date medication started:
Medication(s): This person is not infectious. He/she may always have a positive TB skin test, so there is no reason to repeat the test. If you need any further information, please contact this office. Signature of Provider _______________________ Last Reviewed: 05/18/2008 |
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If you would like to order any of the DTBE publications please visit the online order form. You will need Adobe Acrobat™ Reader v5.0 or higher to read pages that are in PDF format. Download the Adobe Acrobat™ Reader. If you have difficulty accessing any material on the DTBE Web site because of a disability, please contact us in writing or via telephone and we will work with you to make the information available. Division of Tuberculosis Elimination
Centers for Disease Control & Prevention |