Download TB (Tuberculosis) Screening Test Results

Brandeis University Health Center
Medical Evaluation for Latent Tuberculosis Infection (LTBI)
(To be completed and signed by a licensed medical provider)
Student’s Name: ________________________________________________ Date of Birth: ___________________
A.
TUBERCULIN SKIN TEST (Mantoux)
Test must be read by a health care provider 48 – 72 hours after administration. If no induration, indicate “0mm”.
Results of multiple puncture tests, such as Tine or Mono-Vac are NOT accepted.
Date administered: ____/____/____ Lot: ________________________ Exp date: ____________________________
Date test read: ____/____/____ Result: _____ mm of induration (sign bottom of page)
OR
B.
Interferon Gamma Release Assay (IGRA) (Copy of Lab Report REQUIRED-Please attach)
Date obtained: ____/____/____ Specify Method: QFT-GIT
Result: ☐Negative
T-Spot
☐ Positive ☐Indeterminate
other ________
☐ Borderline (T-Spot only)
Interpretation of Tuberculin Skin Test
Risk Factor
Positive Result
Close contact with a case of tuberculosis
5 mm or more
Born in a country that has a high rate of tuberculosis
10 mm or more
Traveled or lived for a month or more in a country that
10 mm or more
has a high rate of Tuberculosis
No risk factors (test not recommended)
15 mm or more
C.
If Tuberculin Skin Test or IGRA is POSITIVE, now, or by history, the following are REQUIRED:
1. Date of positive PPD or IGRA: ____/____/_____ Results _________ mm.
2. Chest X-ray: Copy of X-ray Report REQUIRED. Date of X-ray: ____/____/____
☐Normal ☐ Abnormal ______________________________________________ (Describe)
3. Clinical Evaluation:
☐Normal ☐ Abnormal ______________________________________________ (Describe)
4. Treatment:
☐No ☐ Yes ___________________________________________ (Drug, dose, frequency and dates)
HEALTHCARE PROVIDER SIGNATURE (REQUIRED): ____________________________________________________
Date: __________________ Tel: (________)________________________________ Fax: (________)________________________