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Get PA Baseline Two-Step PPD

D.O.B: HAVE YOU PREVIOUSLY HAD A POSITIVE RESULT FROM A PPD SKIN TEST: YES NO (IF YES, A CHEST X-RAY WITHIN THE PAST 5 YEARS IS REQUIRED – ATTACH REPORT) UNLESS DOCUMENTATION CAN BE PROVIDED TO INDICATE A NEGATIVE BASELINE TWO-STEP PPD WITHINTHE PAST TWELVE MONTHS, A BASELINE TWO-STEP PPD IS REQUIRED. #1 PPD skin test/annual PPD skin test given: Site: Left: Manufacturer: Lot #: Expiration Date: Administered by: (Full signature) Date/time: Right PPD READINGS: 48-72 HOURS AFTER ADMINISTR.

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