TB Skin Test Form (Employee)
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224-D Cornwall St. NW
Suite 403
Leesburg, VA 20176
Phone: (703) 737-6001 Fax: (703) 443-8174
___________________________________
PPD SKIN TEST
Employee Name: ____________________________________
Date of last PPD skin test: _____________________________
Have you ever had a positive reaction? ____________________
Have you ever had a BCG vaccine? _______________________
Are you pregnant? ___________________________________
Date of PPD placement: ______________ Arm: R ____ L ____
0.1 cc I.D. Manufacturer: __________ Lot# ______ Exp______
Given by: __________________________
Date read: ___________ By: ____________
RESULT: Positive ______ Negative ______
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