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Get CA CDC 7336 2002

Reset Form Print Form STATE OF CALIFORNIA DEPARTMENT OF CORRECTIONS AND REHABILITATION EMPLOYEE TUBERCULIN SKIN TEST TST AND EVALUATION CDC 7336 Rev. 10/02 INSTRUCTIONS Tuberculosis TB screening must be performed by a licensed health care provider whose legally authorized scope of practice allows him/her to conduct medical examinations and/or the Mantoux TB Skin Test TST in accordance with the recommendations of the Centers for Disease Control and Prevention to determine if a person has TB infection or disease. EMPLOYEE INFORMATION PRINT OR TYPE EMPLOYEE S FULL NAME AS IT APPEARS ON STATE PAYCHECK FIRST MI LAST GENDER MALE BIRTHDATE LAST 6 DIGITS OF SOCIAL SECURITY NUMBER NEW EMPLOYEE/CADET YES NO INSTITUTION OR DIVISION UNIT OR BRANCH DEPARTMENT IF NOT CDCR EMPLOYEE SIGNATURE FEMAILE DATE PRIOR TST/TB HISTORY AS DOCUMENTED IN THE EMPLOYEE HEALTH CARE RECORD NOTE PRIVATE PROVIDERS ATTACH DOCUMENTATION OF PRIOR HISTORY PRIOR SIGNIFICANT TB SKIN TEST/INFECTION IF YES DATE INDURATION SIZE MM PRIOR TB DISEASE O B CHECK ONE TUBERSOL APILSOL INJECTION SITE LFA RFA LOT NUMBER NO SYMPTOMS TST ADMINISTRATION 5 TU/0. EMPLOYEE INFORMATION PRINT OR TYPE EMPLOYEE S FULL NAME AS IT APPEARS ON STATE PAYCHECK FIRST MI LAST GENDER MALE BIRTHDATE LAST 6 DIGITS OF SOCIAL SECURITY NUMBER NEW EMPLOYEE/CADET YES NO INSTITUTION OR DIVISION UNIT OR BRANCH DEPARTMENT IF NOT CDCR EMPLOYEE SIGNATURE FEMAILE DATE PRIOR TST/TB HISTORY AS DOCUMENTED IN THE EMPLOYEE HEALTH CARE RECORD NOTE PRIVATE PROVIDERS ATTACH DOCUMENTATION OF PRIOR HISTORY PRIOR SIGNIFICANT TB SKIN TEST/INFECTION IF YES DATE INDURATION SIZE MM PRIOR TB DISEASE O B CHECK ONE TUBERSOL APILSOL INJECTION SITE LFA RFA LOT NUMBER NO SYMPTOMS TST ADMINISTRATION 5 TU/0. 1 milliliter EXPIRATION DATE TST ADMINISTERED BY PRINT NAME SIGNATURE INTERPRETATION TST RESULT M INDURATION DATE TST READ/OR OF SIGN SYMPTOM EVALUATION EVALUATION FOR SIGNS AND SYMPTOMS MUST BE COMPLETED FOR ALL INDIVIDUALS SYMPTOMS CHECK ALL THAT APPLY WEIGHT LOSS UNEXPLAINED UNEXPLAINED FATIGUE PERSISTENT 2 WKS COUGH UNEXPLAINED FEVER UNEXPLAINED NIGHT SWEATS CHEST XRAY NEEDED CHEST XRAY REPORT ON FILE COPY REQURIED CHEST XRAY CHEST XRAY RESULT NORMAL CONSISTENT W/TB COMMENTS EMPLOYEE REFERRED FOR FOLLOWUP MEDICAL EVALUATION EMPLOYEE PROVIDED WRITTEN NOTIFICATION OF TST RESULTS NO SHOWEMPLOYEE NOTIFIED EMPLOYEE IS FREE OF INFECTIOUS TUBERCULOSIS EVALUATOR NAME LFA LEFT FOREARM RFA RIGHT FOREARM EVALUATOR SIGNATURE. EMPLOYEE INFORMATION PRINT OR TYPE EMPLOYEE S FULL NAME AS IT APPEARS ON STATE PAYCHECK FIRST MI LAST GENDER MALE BIRTHDATE LAST 6 DIGITS OF SOCIAL SECURITY NUMBER NEW EMPLOYEE/CADET YES NO INSTITUTION OR DIVISION UNIT OR BRANCH DEPARTMENT IF NOT CDCR EMPLOYEE SIGNATURE FEMAILE DATE PRIOR TST/TB HISTORY AS DOCUMENTED IN THE EMPLOYEE HEALTH CARE RECORD NOTE PRIVATE PROVIDERS ATTACH DOCUMENTATION OF PRIOR HISTORY PRIOR SIGNIFICANT TB SKIN TEST/INFECTION IF YES DATE INDURATION SIZE MM PRIOR TB DISEASE O B CHECK ONE TUBERSOL APILSOL INJECTION SITE LFA RFA LOT NUMBER NO SYMPTOMS TST ADMINISTRATION 5 TU/0. 1 milliliter EXPIRATION DATE TST ADMINISTERED BY PRINT NAME SIGNATURE INTERPRETATION TST RESULT M INDURATION DATE TST READ/OR OF SIGN SYMPTOM EVALUATION EVALUATION FOR SIGNS AND SYMPTOMS MUST BE COMPLETED FOR ALL INDIVIDUALS SYMPTOMS CHECK ALL THAT APPLY WEIGHT LOSS UNEXPLAINED UNEXPLAINED FATIGUE PERSISTENT 2 WKS COUGH UNEXPLAINED FEVER UNEXPLAINED NIGHT SWEATS CHEST XRAY NEEDED CHEST XRAY REPORT ON FILE COPY REQURIED CHEST XRAY CHEST XRAY RESULT NORMAL CONSISTENT W/TB COMMENTS EMPLOYEE REFERRED FOR FOLLOWUP MEDICAL EVALUATION EMPLOYEE PROVIDED WRITTEN NOTIFICATION OF TST RESULTS NO SHOWEMPLOYEE NOTIFIED EMPLOYEE IS FREE OF INFECTIOUS TUBERCULOSIS EVALUATOR NAME LFA LEFT FOREARM RFA RIGHT FOREARM EVALUATOR SIGNATURE. .

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