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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