_TUBERCULIN SKIN TEST FORM
TUBERCULIN SKIN TEST AUTHORIZATION FORM
Employee Name/Title:
Position:
I have been informed of the requirement that all employees must have documented evidence of a negative tuberculin skin test and/or documentation of a previously positive result with accompanying evidence of evaluation and/or treatment. I hereby authorize the Agency to administer a Tuberculin skin test to me.
I have been informed of the requirement that a tuberculosis history and health assessment be completed prior to accepting assignment with a home care client, and agree to cooperate with this requirement.
Employee Signature:______________________________________________ Date:______________________
for office use only:
Date administered:
Dose:
Lot Number: Expiration Date:
Site:
Administered by - Signature/Title:
Date results read (within 48-72 hours):
Results in mm of induration:
Read by - Signature/Title:
Follow up action if results are significant:
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Company Name and Logo
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