SKILLS VALIDATION FORM - Georgia Department of Public …



TB UPDATE & TUBERCULIN SKIN TEST CERTIFICATION

SKILLS VALIDATION RENEWAL FORM

(Frequency of Renewal: Every Two Years From Date of Initial Class)

1. View the CDC Tuberculin Skin Testing (Mantoux) video, current version. Date of version__________.

2. A supervised skills validation of administering, reading and classifying five skin tests.

3. Review a copy of the Georgia TB Reference Guide, current year. Date of current version__________.

4. Attach a copy of your last certificate.

Name:________________________________________________________________________________________

Mailing Address:

(street, city, state, zip)___________________________________________________________________________

|Date of Initial Class |

Please check type of facility:

|( Health Department |( Physician’s Office |( County or City Jail |

|( Hospital |( Out Patient Clinic |( Federal Prison |

|( Nursing Home |( Personal Care Home |( State DOC |

|( Mental Health |( HIV/AIDS affiliation |( Juvenile Detention |

|( Hospice |( Community Based Organization |( Other ________________ |

|( Substance Abuse |( Shelter | |

|( Home Health |( School | |

Employer:______________________________________________________________________________________

Position:_______________________________________________________________________________________

Employer address:_______________________________________________________________________________

City:______________________________________________ State:_________________ Zip:__________________

Work Phone:________________________ Fax:_______________________ Home Phone:_____________________

Email:_________________________________________________________________________________________

|Date of TST |Signature/ phone # of Person Observing & |Check if |Date of TST |Signature/ phone # of Person Observing & |Check if |

|Administration |Verifying Competency |competent |Reading |Verifying Competency |competent |

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Please mail checklist to: Nurse Educators, c/o Georgia TB Program, 2 Peachtree St., NW, 12. 476, Atlanta, GA 30303. or fax to 404-463-3460

- KEEP COPY FOR YOUR RECORDS! For more information, call (404) 657-2634. (Rev. 04/2011)

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