Get AmeriCorps ABC Foster Grandparent/Senior Companion Program TB Test Form 2022-2024

Positive Tuberculosis TB Test Screening Form Please fill out only if the volunteer has had a POSITIVE TB test in the past. Appendix C. 11 - Sample FGP-SCP TB Test Form ABC Foster Grandparent/Senior Companion Program Address Phone Email address or fax number Note TB Tests are not required by Senior Corps but are required by some sponsoring agencies and volunteer stations. 1 Pg. 1 of 2 This document is provided as a sample ONLY. Its use is optional and if used it should be customized as appropriate. Date of Positive Test Results Was a chest X-ray done at that time If yes was it normal Yes No Did volunteer receive anti-TB medication Yes How long did they take it Date of last chest X-ray What was the result If POSITIVE within the last year has volunteer been treated for Unusual/persistent cough Coughing up blood Shortness of breath Persistent fever/chills Night sweats Unexplained weight loss Chronic fatigue Known TB exposure Comments and/or follow-up. PPD Test Date Date Read of mm induration Results/Interpretation PROVIDER INFORMATION REQUIRED Health Professional Signature Hospital/Clinic/Organization Name Date IF PREVIOUS POSITIVE RESULTS SKIP TEST AND GO TO THE NEXT PAGE Version 2017. TB Test Form Name Date of Birth Address Phone A TB test is required to participate in the ABC Foster Grandparent/Senior Companion Program. If the volunteer has had a positive TB test in the past please skip this test and complete the next page.