TEXAS DEPARTMENT OF HEALTH
TEXAS DEPARTMENT OF STATE HEALTH SERVICES
TUBERCULIN SKIN TEST
PEDIATRIC POSITIVE REACTOR WORK SHEET
Reporting Agency Date of Test Results mm
Child’s Name DOB
Address Child’s Race: ( White
( Black or African American
Parent or Guardian ( Asian
( Native Hawaiian or Pacific Islander
Results of Child’s Evaluation ( American Indian or Alaskan Native
Chest x-ray ( Normal ( Abnormal ( Unknown
Diagnosis ( M. TB Infection, No Disease Child’s Ethnicity: ( Hispanic or Latino
( M. TB Infection, Current Disease ( Not Hispanic or Latino
( M. TB, No Current Disease ( Unknown
( M. TB Suspect, Diagnosis Pending
|Associate’s Identity |LTBI Test Results |Chest X-Ray Results |Remarks* |
Name and Address |Relationship |DOB |Date |Mantoux |Other |Date | | | | | |
/ / |
/ / |
mm | |
/ / |( No Evidence of TB
( Abnormal - Suggestive of TB | | | | |
/ / |
/ / |
mm | |
/ / |( No Evidence of TB
( Abnormal - Suggestive of TB | | | | |
/ / |
/ / |
mm | |
/ / |( No Evidence of TB
( Abnormal - Suggestive of TB | | | | |
/ / |
/ / |
mm | |
/ / |( No Evidence of TB
( Abnormal - Suggestive of TB | | | | |
/ / |
/ / |
mm | |
/ / |( No Evidence of TB
( Abnormal - Suggestive of TB | | | | |
/ / |
/ / |
mm | |
/ / |( No Evidence of TB
( Abnormal - Suggestive of TB | | |* Include presence or absence of symptoms of TB disease, results of sputum smear or culture, etc.
TB – 318 Rev. 12/07
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