Get University of West Georgia TB/PPD Test Results 2009-2024

School of Nursing 1601 Maple Street Carrollton Georgia 30118 TB/PPD Test Results Student Name Proof of a negative TB skin test must be obtained EVERY YEAR and must not expire during the clinical experience. All fields must be completed for this form to be valid. TUBERCULOSIS Check one Tuberculosis Skin Test Mantoux Purified Protein Derivative PPD Date of Injection Date of reading 48-72 hours after date of injection Reading mm Circle one POSITIVE NEGATIVE If student has a history of a positive PPD or Bacilli Calmette-Guerin BCG vaccine then the following should apply Initial documentation for students with a positive PPD must include Most recent positive PPD most recent chest x-ray summary current and/or past treatment record as well as a letter from a nurse practitioner physician assistant or medical doctor stating that the student is free and clear of all signs and symptoms of TB to participate in clinical activities. A doctor s note must be obtained each year for students with a positive PPD record. recommended by the Centers for Disease Control and Prevention CDC. School of Nursing 1601 Maple Street Carrollton Georgia 30118 TB/PPD Test Results Student Name Proof of a negative TB skin test must be obtained EVERY YEAR and must not expire during the clinical experience. All fields must be completed for this form to be valid* TUBERCULOSIS Check one Tuberculosis Skin Test Mantoux Purified Protein Derivative PPD Date of Injection Date of reading 48-72 hours after date of injection Reading mm Circle one POSITIVE NEGATIVE If student has a history of a positive PPD or Bacilli Calmette-Guerin BCG vaccine then the following should apply Initial documentation for students with a positive PPD must include Most recent positive PPD most recent chest x-ray summary current and/or past treatment record as well as a letter from a nurse practitioner physician assistant or medical doctor stating that the student is free and clear of all signs and symptoms of TB to participate in clinical activities. A doctor s note must be obtained each year for students with a positive PPD record. recommended by the Centers for Disease Control and Prevention CDC. All students who take 5 or more credit hours per semester on the main Carrollton campus who have paid health fees at UWG may have the TB Skin test completed at University Health Services for no charge. However there will be a charge if other tests are ordered* TB tests at UWG Health Services can only be done on Mondays Tuesdays and Wednesdays due to they have to be read within 48 to 72 hours. Signature of Nurse Practitioner Physician Assistant or Medical Doctor Date Facility Address Created 11/10/09. All fields must be completed for this form to be valid* TUBERCULOSIS Check one Tuberculosis Skin Test Mantoux Purified Protein Derivative PPD Date of Injection Date of reading 48-72 hours after date of injection Reading mm Circle one POSITIVE NEGATIVE If student has a history of a positive PPD or Bacilli Calmette-Guerin BCG vaccine then the following should apply Initial documentation for students with a positive PPD must include Most recent positive PPD most recent chest x-ray summary current and/or past treatment record as well as a letter from a nurse practitioner physician assistant or medical doctor stating that the student is free and clear of all signs and symptoms of TB to participate in clinical activities. A doctor s note must be obtained each year for students with a positive PPD record. recommended by the Centers for Disease Control and Prevention CDC. .