*PLEASE RETURN ALL FORMS TO: ROOM 209*
Kennesaw State University ~ WellStar School of Nursing~ Physical Exam Requirements ~Name_____________________________Date of Birth___________________KSU ID___________________________Phone Number_________________E-mail____________________________PPD Update PPD date ___________ measurement of induration in millimeters________________Date of annual symptom-free screen ______________ (for those who have been exposed to TB and have positive PPDs)Chest x-ray date ___________________________(only if PPD or annual symptom screen reading is Positive and bring copy of X-ray report with this form)Current treatment for latent TB, please include medication dose, frequency and duration_________________________________________________________Quantiferon test result ____________________ Date of test ___________(only if PPD reading is Positive and attach lab results to this form)Health Care Provider’s Signature:______________________________ Date:_________Health Care Provider’s Name (Print):_________________________________________Address:________________________________________________________________Phone Number:___________________________________________________________*PLEASE RETURN FORM TO: Lisa Longeiret(via email llongeir@kennesaw.edu or fax (470) 578-9066 or room 3016 in Prillaman Hall) ................
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