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U.S. Department of Health and Human Services


Guide for Primary Health Care Providers: Targeted Tuberculin Testing and Treatment of Latent Tuberculosis Infection

Appendix D

Sample TST and Treatment Documentation Forms

Tuberculin Skin Test Record

To Whom It May Concern:

The following is a record of Mantoux tuberculin skin testing:


Date of birth:                                       

Date and time test administered:                                           

Administered by:                                  

Manufacturer of PPD:                                      

Expiration date:              

Lot Number:                                      

Date and time test read:            ­­­­­          
Read by:                                


Results (in millimeters of induration):                             

Treatment Completion Letter

To Whom It May Concern:

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


Date of birth:   __________________

TST:  Date:_____ 
Results (in millimeters of induration):                  

Chest radiograph: Date:                         

Date medication started:                                   
Date completed:                                             


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 ___________________


Released October 2008
Centers for Disease Control and Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of Tuberculosis Elimination -

Please send comments/suggestions/requests to:, or to
CDC/Division of Tuberculosis Elimination
Communications, Education, and Behavioral Studies Branch
1600 Clifton Rd., NE - Mailstop E-10, Atlanta, GA 30333