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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
2005

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:

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):                             

Treatment Completion Letter

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):                  

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 ___________________

 


Released October 2008
Centers for Disease Control and Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of Tuberculosis Elimination - http://www.cdc.gov/tb

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