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Get History of Positive TB Skin Test Form

History of Positive TB Skin Test Form If you have had a positive TB skin test in the past please complete this form and return this form to Employee Health Service EHS 800 University Bay Drive Madison WI 53705. MC 6715 FAX 262-7284 Date Phone Employee ID Job Classification Date of Birth Department Current guidelines recommend not repeating the TB skin test nor doing annual chest x-rays in the absence of signs and symptoms of TB. PLEASE ANSWER ALL OF THE FOLLOWING l* Date of your most recent TB skin test Date Result Where done Prior Chest X-ray s Date s Result s History of Previous TB Infection/Disease Yes/No Treatment with INH or Other Antituberculosis Therapy If yes dates of treatment History of BCG If yes specify country of birth Signs/Symptoms of TB Fatigue Night Sweats Cough 2 weeks Weight Loss Fevers If you answer yes to any of the above signs/symptoms discuss immediately with EHS staff present or contact EHS at 263-7535 to review. If at anytime you develop signs/symptoms listed above contact EHS immediately. Call EHS if you have any questions. MC 6715 FAX 262-7284 Date Phone Employee ID Job Classification Date of Birth Department Current guidelines recommend not repeating the TB skin test nor doing annual chest x-rays in the absence of signs and symptoms of TB. PLEASE ANSWER ALL OF THE FOLLOWING l* Date of your most recent TB skin test Date Result Where done Prior Chest X-ray s Date s Result s History of Previous TB Infection/Disease Yes/No Treatment with INH or Other Antituberculosis Therapy If yes dates of treatment History of BCG If yes specify country of birth Signs/Symptoms of TB Fatigue Night Sweats Cough 2 weeks Weight Loss Fevers If you answer yes to any of the above signs/symptoms discuss immediately with EHS staff present or contact EHS at 263-7535 to review. PLEASE ANSWER ALL OF THE FOLLOWING l* Date of your most recent TB skin test Date Result Where done Prior Chest X-ray s Date s Result s History of Previous TB Infection/Disease Yes/No Treatment with INH or Other Antituberculosis Therapy If yes dates of treatment History of BCG If yes specify country of birth Signs/Symptoms of TB Fatigue Night Sweats Cough 2 weeks Weight Loss Fevers If you answer yes to any of the above signs/symptoms discuss immediately with EHS staff present or contact EHS at 263-7535 to review. If at anytime you develop signs/symptoms listed above contact EHS immediately. Call EHS if you have any questions. MC 6715 FAX 262-7284 Date Phone Employee ID Job Classification Date of Birth Department Current guidelines recommend not repeating the TB skin test nor doing annual chest x-rays in the absence of signs and symptoms of TB. PLEASE ANSWER ALL OF THE FOLLOWING l* Date of your most recent TB skin test Date Result Where done Prior Chest X-ray s Date s Result s History of Previous TB Infection/Disease Yes/No Treatment with INH or Other Antituberculosis Therapy If yes dates of treatment History of BCG If yes specify country of birth Signs/Symptoms of TB Fatigue Night Sweats Cough 2 weeks Weight Loss Fevers If you answer yes to any of the above signs/symptoms discuss immediately with EHS staff present or contact EHS at 263-7535 to review. If at anytime you develop signs/symptoms listed above contact EHS immediately. Call EHS if you have any questions.

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