Record of Tuberculosis Screening: Two Step
Student Name: ___ DOB: ___
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Office Stamp/Address & Phone Number
Type of Screening (check one):
Tuberculin Skin Test (TST)
IGRA
IGRA
TST testing: If initial testing for tuberculosis, student must have a two-step TST once. Results must be recorded in millimeters. Positive, negative or +/- are not acceptable. Results must be read in 48-72 hours.
Date/Time Administered: ___ Administered by: ___
Date/Time TST read: _____ Read by:
Results in mm: ___ Interpretation: ☐ Negative
Positive
Step 2: (repeat in 1-3 weeks):
Date/Time Administered: ___ Administered by: ___
Date/Time TST read: ___
Read by:
Results in mm: ___ Interpretation: ☐ Negative
□ Positive
Positive
QuantiFERON Gold testing (recommended if immunized with BCG or a previous positive TST test):
Results: ___ *
*A copy of lab result must be included with this form.