Tuberculosis Testing Record
Exam Date :
Student Name ________________________________________________________________ Address ______________________________________________________________________ City __________________________________________ State ________ Zip ________________
Initial Test Date Given __________________ Date Read __________________ Results _______________
Initial test MUST be read within 48-72 hours . If initial test results are positive , a chest x- ray is required to verify no active disease is present .
Positive findings / Results of follow-up chest x-ray :
Physician _____________________________________ Phone __________________________ Address ______________________________________________________________________ City __________________________________________ State ________ Zip ________________
Physicians Signature __________________________________________________________
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