Baa aval Certificate of TB (tuberculosis) Screenin ew BAName) TEC) sured en oem) oO OF) 'S}#1 (Phone Number) AA ADate of Birth) GAAS Passport Number) (Address) 1. HAE 8 (Medical examination results) 1. 21 BY 4122418 treatment history): A. BB(No) OB. MB (Yes) CC. ALB S(Under treatment) 0 2. BH YNBAigns & Symptoms suggestive of TB): A. SB(No) OB. WS(Ves) O 3. SEX BAL UAt(Date of Chest X-ray): _dd_/ mm _/ ywy A. B8(Normal) 8. BAL SE 4|BSIAA(Cured or Inactive TB) 0 C. Be F2ASuspected active TB) 1 4. 7HSHAAL UX}(Date of sputum examination): __dd_/ mm _/ ywy 1) AHEtSAAAbSputum AFB smear): A. SAl(Negative) 1 B. V4I(Positive) 2) 7HEtHHSFAALSputum M Tuberculosis culture): A Sd(Negative) 0 B. Q44(Positive) 3) HAHSSAANTB PCR): A. SA(Negative) 1 B. 44(Positive) C1 C. OIAIS4(Not done) (1 Il, Zzb(nterpretation) 1, BAS OFel(No active TB) 2.358 Bil SE Bal | 4 (Active TB or suspected 1B) O AM ZO| Arseasuect. The examination was performed as above BS|HSilicense No): 7 SIAR (Name of Physician): AB EE signature) Naa | (Summary of the examination) | S| DAALAS| Sty Also CHEE Ola (Remarks about examinee’s domestic stay) [+ BIQAI OlAp O24] Ate (Additional close examination) i (ttach doctor's Sito i letter, if needed) #1 ABO| Het 212 Sey 7k ATS sia} Zol Bereuicy We hereby certify that the examinee's heath status is assessed as above. dd. mm. yyyy. OOOO #7/7H8 (22) (OOOO Chief of Hospital) (signature)