Download It is mandatory that each candidate for the Certified Nursing

Moe Shea Corporation Vocational Training Institute
It is mandatory that each candidate for the Certified Nursing Assistant receive Tuberculin
Screening. This can be done at your local TB clinic or your private physician or clinic. You
MUST have a 2-step Mantoux prior to the start of the program.
Name:
FIRST MANTOUX:
Mantoux Given: ___/___/___
Site:
L
‫ٱ‬
R
‫ٱ‬
Administered By:
Forearm
‫ٱ‬
Lot #
Expiration Date:
Read By:
Results:
Neg. ‫ٱ‬
Pos. ‫ٱ‬
mm induration
Pos. ‫ٱ‬
mm induration
Date:
SECOND MANTOUX:
Mantoux Given: ___/___/___
Site:
L
‫ٱ‬
R
‫ٱ‬
Administered By:
Forearm
‫ٱ‬
Lot #
Expiration Date:
Read By:
Results:
Neg. ‫ٱ‬
Date:
Previous positive skin reaction requires a chest x-ray be done
Chest x-ray date: Date:
results must be attached