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Latent Tuberculosis Infection: A Guide for Primary Health Care Providers

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Appendix E

SAMPLE DOCUMENTATION FORMS

Record of TB Skin Test

To Whom It May Concern:

The following is a record of Mantoux tuberculin skin testing:

Name:______________________________________________

Date of birth: ________________________________________

Date and time test administered: __________________________

Administered by: _____________________________________

Manufacturer of PPD:__________________________________

Expiration date: __________________ Lot Number:__________

Date and time test read: ____________ Read by: ____________

Date:______________________________________________

Results (in millimeters of induration)_________________


Record of Interferon-Gamma Release Assay for TB

To Whom It May Concern:

The following is a record of IGRA results:

Name:___________________________________________________

Date of birth:______________________________________________

Type of test:________________________ Date:__________________

Laboratory:_______________________________________________

Qualitative result:____________________ Nil (IU IFN-g):___________

Mitogen (IU IFN-g): ___________ M. tb antigens (IU IFN-g):______


Record of Treatment Completion

To Whom It May Concern:

The following is a record of evaluation and treatment for M. tuberculosis infection:

Name:_________________________ Date of birth:_____________

TST: Date:_____________ Results (in millimeters of induration):____

IGRA: Date:_____________ Type of test:________ Result:_________

Chest radiograph: Date:____________ Results:_________________

Date medication started:___________ Date completed:___________

Medication(s):___________________________________________

______________________________________________________

This person is not infectious. He/she may always have a positive TB skin test, so there is no reason to repeat the test. If you need any further information, please contact this office.

Signature of Provider_____________________________________

Date__________________________________________________

 
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  • Page last reviewed: September 11, 2012
  • Page last updated: September 11, 2012
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