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KENTUCKY STATE UNIVERSITY
School of Nursing
400 EAST MAIN STREET
FRANKFORT, KENTUCKY 40601
PHONE: (502) 597-5957
FAX: (502) 597-5818
www.kysu.edu
Record of Tuberculosis Screening: Two Step
Student Name: ___ DOB: ___
Student Name
DOB
<div style="text-align: center;"><img src="imgs/img_in_image_box_4_26_1028_296.jpg" alt="Image" width="99%" /></div>
Office Stamp/Address & Phone Number
Office Stamp/Address & Phone Number
Type of Screening (check one):
Tuberculin Skin Test (TST)
IGRA
Type of Screening (check one
IGRA
Tuberculin Skin Test (TST
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.
Step 1:
Date/Time Administered: ___ Administered by: ___
Date/Time Administered
Administered by
Read by
Date/Time TST read: _____ Read by:
Date/Time TST read
Results in mm: ___ Interpretation: ☐ Negative
Results in mm
Negative
Positive
Positive
Step 2: (repeat in 1-3 weeks):
Date/Time Administered: ___ Administered by: ___
Date/Time Administered
Administered by
Date/Time TST read: ___
Date/Time TST read
Read by
Read by:
Results in mm: ___ Interpretation: ☐ Negative
□ Positive
Results in mm
Negative
Positive
Positive
QuantiFERON Gold testing (recommended if immunized with BCG or a previous positive TST test):
Results: ___ *
Results
*A copy of lab result must be included with this form.