St. Alexius Hospital ‘Tuberculin Test Record _LSN studont New employee, initial soresning X current employee, annuat sereening, Contact investzn ___ Post TB contact investigation nuoiber one OntTCY Seowlt owe: 227% Occupation: NURI? paw: 2/2q/1@ Have you hada history ofa previous postive reaction ton TB test? _Yes No ‘ifabove is YES, what yeor? What treatment did you receive Year of last negative chest x-ray: none INK ve yaohavngany mp iistine? Xtone__Chrniceongt _Na swat Bloody sputum ‘Unexpiained weight loss ___ Unexplained fevers Chest pain ave you ha contact with anyone with active TB! (Cun, ands ets) _Yes X_No Since your last TE ski Have you received Bacilli Calmette Guerin (BCG) vaccine? ver X No rove, [Eno is answered to all thé above questions, | hereby consent co have This test must read within 48-72 hous after receiving it a Paisano enema Signature of Patient/Guardiao: W have read and answered the questions abi PPD test, which screens for tubercutosis, Employee Health Completes This Sethe BUI 4 Qu pL 5 TUPP-D nbyouln given itradenaly Date of step PPD: SESLH/IB. ee Ne Taster prot: GSOHOS) Stegivensay Left Right Times|Zeo_ Administered by Results: mm_ Date read! BUI Time}9ee juation? Yes _— Referred for Date of t"'step PPD: _/_! Manufacturer See eae Site given: Left Right Time: Administered by! mmm “Date read: ff Timet_ Really: Referred for evaluation? __Yos