TUBERCULOSIS SKIN TEST FORM

Patient Name: ______________________________________________________

Testing Location (address): ____________________________________________
Date Placed: ________________________________________________________
Time Administered: __________________________________________ AM / PM
Site: Right Left
Lot # ______________________ Expiration Date: ___________________
Signature (administered by): _______________________________________
RN MD Other: _____________________

Date Read (within 48 – 72 Hours): _______________________________________

Time Read: __________________________________________________ AM / PM
Induration (please note in mm): ___________________________________mm
PPD (Mantoux) Test Result: Negative Positive
Signature (results read/reported by): ____________________________________
RN MD Other: ________________________

*In order for this document to be valid/acceptable, all sections of this form must be completed.

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