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For University use Place label here 207 Fletcher Street Ann Arbor MI USA 48109-1050 www. uhs. umich. edu/tbscreen Email tbscreen umich. edu Documentation for International Mandatory Tuberculosis TB Screening Certain entering international students must be screened for TB at University of Michigan U-M. Screening is free and confidential on campus. You may also use this form for documentation to help meet the requirement. Bring this completed form with you to your screening appointment do not submit it before your appointment. Acceptable documentation is must be in English Negative QuantiFERON-TB Gold or T-SPOT. TB test done in the U*S* within a year of starting U-M classes OR Completed treatment report for active or inactive TB Unacceptable documentation is TB skin test Mantoux PPD skin test Tine test Chest x-ray only A health care provider should complete this form in English Patient -- Name Last family First Date of Birth Month QuantiFERON-TB Gold T-SPOT. TB test Date Test -- Day Middle initial Month Year Result Negative Indeterminate - further testing will be required at U-M Positive - further testing will be required at U-M Treatment for Tuberculosis -- Describe treatment including dates Health Care Provider Who Completed this Form Printed name Signature Street Address City State Country if not USA Postal zip code resultform 5/11/2015 jis. edu/tbscreen Email tbscreen umich. edu Documentation for International Mandatory Tuberculosis TB Screening Certain entering international students must be screened for TB at University of Michigan U-M. Screening is free and confidential on campus. You may also use this form for documentation to help meet the requirement. Screening is free and confidential on campus. You may also use this form for documentation to help meet the requirement. Bring this completed form with you to your screening appointment do not submit it before your appointment. Bring this completed form with you to your screening appointment do not submit it before your appointment. Acceptable documentation is must be in English Negative QuantiFERON-TB Gold or T-SPOT. TB test done in the U*S* within a year of starting U-M classes OR Completed treatment report for active or inactive TB Unacceptable documentation is TB skin test Mantoux PPD skin test Tine test Chest x-ray only A health care provider should complete this form in English Patient -- Name Last family First Date of Birth Month QuantiFERON-TB Gold T-SPOT. Acceptable documentation is must be in English Negative QuantiFERON-TB Gold or T-SPOT. TB test done in the U*S* within a year of starting U-M classes OR Completed treatment report for active or inactive TB Unacceptable documentation is TB skin test Mantoux PPD skin test Tine test Chest x-ray only A health care provider should complete this form in English Patient -- Name Last family First Date of Birth Month QuantiFERON-TB Gold T-SPOT. TB test Date Test -- Day Middle initial Month Year Result Negative Indeterminate - further testing will be required at U-M Positive - further testing will be required at U-M Treatment for Tuberculosis -- Describe treatment including dates Health Care Provider Who Completed this Form Printed name Signature Street Address City State Country if not USA Postal zip code resultform 5/11/2015 jis.