Tuberculosis (TB) Skin Test Form

Please complete and return this form to the Employee Health Clinic:
Scan/Email: EmployeeHealth.clinic@UTMB.edu
Fax: (409) 747-9182
Mail: EHC, 301 University Blvd., Primary Care Pavilion, Suite 125, Galveston, TX 77555-1161

Part A: Employee Information

Employee name: Date:

___________________________________________________________________ _______________________________

Department: Employee ID:

___________________________________________________________________ _______________________________

Have you ever had a positive TB test? Yes No

Part B: TB Skin Testing

Please inform tester if you may be pregnant.

Tuberculin purified protein derivative (PPD) for intracutaneous (Mantoux) tuberculin testing please check one:
Step #1 Step #2 Annual testing Post-exposure 12 weeks post-exposure
Date administered: Site: Dose/Route:
_______________________________ Right forearm Left forearm 0.1 ml of 5 tuberculin units/intracutaneous

Manufacturer: Lot number: Expiration date:

_______________________________ _______________________________ _______________________________

Name of person applying the test: Phone number:

___________________________________________________________________ _______________________________

Department/Business address:
______________________________________________________________________________________________________

Signature of person applying the test: Date:

___________________________________________________________________ _______________________________

Part C: TB Skin Test Reading Results (48 72 hours after placement)

Date of reading: Millimeters (mm) induration:

_______________________________ _______________________________

Name of person who read the test: Phone number:

___________________________________________________________________ _______________________________

Department/Business address:
______________________________________________________________________________________________________

Signature of person who read the test: Date:

___________________________________________________________________ _______________________________

Human Resources/April 2014