[ { "page": 1, "items": [ { "page": 1, "type": "TITLE", "location": { "l": 158.64, "t": 630.96, "r": 453.12, "b": 613.44 }, "text": "Record of Tuberculosis Screening: Two Step", "reading_order": 0, "level": 1 }, { "page": 1, "type": "TEXT", "location": { "l": 69.12, "t": 578.64, "r": 538.8, "b": 564.24 }, "text": "Student Name: ___ DOB: ___", "reading_order": 1 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 159.12, "t": 586.32, "r": 354.6, "b": 566.64 }, "text": "Student Name", "field_kind": "text", "label": "Student Name", "pdf_field_name": "Student Name", "pdf_field_type": "Text", "reading_order": 2 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 392.64, "t": 586.32, "r": 536.52, "b": 566.64 }, "text": "DOB", "field_kind": "text", "label": "DOB", "pdf_field_name": "DOB", "pdf_field_type": "Text", "reading_order": 3 }, { "page": 1, "type": "TEXT", "location": { "l": 306.48, "t": 563.28, "r": 545.52, "b": 494.88 }, "text": "
\"Image\"
\n", "reading_order": 4 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 308.88, "t": 557.76, "r": 544.32, "b": 496.08 }, "text": "Office Stamp/Address & Phone Number", "field_kind": "text", "label": "Office Stamp/Address & Phone Number", "pdf_field_name": "Office StampAddress Phone Number", "pdf_field_type": "Text", "reading_order": 5 }, { "page": 1, "type": "TEXT", "location": { "l": 69.36, "t": 532.56, "r": 296.4, "b": 516.96 }, "text": "Office Stamp/Address & Phone Number", "reading_order": 6 }, { "page": 1, "type": "TEXT", "location": { "l": 70.08, "t": 486.48, "r": 425.04, "b": 470.16 }, "text": "Type of Screening (check one):", "reading_order": 7 }, { "page": 1, "type": "TEXT", "location": { "l": 264.48, "t": 486.96, "r": 427.68, "b": 470.16 }, "text": "Tuberculin Skin Test (TST)\nIGRA", "reading_order": 8 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 267, "t": 486.24, "r": 284.52, "b": 471.24 }, "text": "Type of Screening (check one", "field_kind": "checkbox", "label": "Type of Screening (check one", "pdf_field_name": "Type of Screening check one", "pdf_field_type": "CheckBox", "reading_order": 9 }, { "page": 1, "type": "TEXT", "location": { "l": 453.36, "t": 487.44, "r": 533.76, "b": 470.4 }, "text": "IGRA", "reading_order": 10 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 456.36, "t": 484.92, "r": 471.12, "b": 472.2 }, "text": "Tuberculin Skin Test (TST", "field_kind": "text", "label": "Tuberculin Skin Test (TST", "pdf_field_name": "Tuberculin Skin Test TST", "pdf_field_type": "Text", "reading_order": 11 }, { "page": 1, "type": "TEXT", "location": { "l": 68.88, "t": 462.24, "r": 541.44, "b": 416.88 }, "text": "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.", "reading_order": 12 }, { "page": 1, "type": "TITLE", "location": { "l": 69.36, "t": 408.72, "r": 111.6, "b": 394.32 }, "text": "Step 1:", "reading_order": 13, "level": 2 }, { "page": 1, "type": "TEXT", "location": { "l": 68.64, "t": 385.44, "r": 539.04, "b": 371.04 }, "text": "Date/Time Administered: ___ Administered by: ___", "reading_order": 14 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 213.24, "t": 393.36, "r": 328.32, "b": 373.68 }, "text": "Date/Time Administered", "field_kind": "text", "label": "Date/Time Administered", "pdf_field_name": "DateTime Administered", "pdf_field_type": "Text", "reading_order": 15 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 428.4, "t": 393.36, "r": 537.84, "b": 373.68 }, "text": "Administered by", "field_kind": "text", "label": "Administered by", "pdf_field_name": "Administered by", "pdf_field_type": "Text", "reading_order": 16 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 379.92, "t": 372.12, "r": 535.56, "b": 352.44 }, "text": "Read by", "field_kind": "text", "label": "Read by", "pdf_field_name": "Read by", "pdf_field_type": "Text", "reading_order": 17 }, { "page": 1, "type": "TEXT", "location": { "l": 69.12, "t": 364.56, "r": 379.44, "b": 350.16 }, "text": "Date/Time TST read: _____ Read by:", "reading_order": 18 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 185.28, "t": 372.12, "r": 323.16, "b": 352.44 }, "text": "Date/Time TST read", "field_kind": "text", "label": "Date/Time TST read", "pdf_field_name": "DateTime TST read", "pdf_field_type": "Text", "reading_order": 19 }, { "page": 1, "type": "TEXT", "location": { "l": 69.84, "t": 343.44, "r": 519.6, "b": 327.84 }, "text": "Results in mm: ___ Interpretation: ā˜ Negative", "reading_order": 20 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 152.28, "t": 350.88, "r": 267.36, "b": 331.2 }, "text": "Results in mm", "field_kind": "text", "label": "Results in mm", "pdf_field_name": "Results in mm", "pdf_field_type": "Text", "reading_order": 21 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 354.48, "t": 344.04, "r": 372, "b": 329.16 }, "text": "Negative", "field_kind": "checkbox", "label": "Negative", "pdf_field_name": "Negative", "pdf_field_type": "CheckBox", "reading_order": 22 }, { "page": 1, "type": "TEXT", "location": { "l": 452.88, "t": 343.68, "r": 520.8, "b": 327.6 }, "text": "Positive", "reading_order": 23 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 453.96, "t": 342.72, "r": 471.48, "b": 327.72 }, "text": "Positive", "field_kind": "checkbox", "label": "Positive", "pdf_field_name": "Positive", "pdf_field_type": "CheckBox", "reading_order": 24 }, { "page": 1, "type": "TEXT", "location": { "l": 69.36, "t": 290.88, "r": 233.52, "b": 276.48 }, "text": "Step 2: (repeat in 1-3 weeks):", "reading_order": 25 }, { "page": 1, "type": "TEXT", "location": { "l": 69.12, "t": 267.6, "r": 536.4, "b": 253.2 }, "text": "Date/Time Administered: ___ Administered by: ___", "reading_order": 26 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 213.24, "t": 275.4, "r": 328.32, "b": 255.72 }, "text": "Date/Time Administered", "field_kind": "text", "label": "Date/Time Administered", "pdf_field_name": "DateTime Administered_2", "pdf_field_type": "Text", "reading_order": 27 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 425.28, "t": 275.4, "r": 534.84, "b": 255.72 }, "text": "Administered by", "field_kind": "text", "label": "Administered by", "pdf_field_name": "Administered by_2", "pdf_field_type": "Text", "reading_order": 28 }, { "page": 1, "type": "TEXT", "location": { "l": 71.04, "t": 246.48, "r": 538.08, "b": 232.32 }, "text": "Date/Time TST read: ___", "reading_order": 29 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 185.28, "t": 254.28, "r": 311.76, "b": 234.6 }, "text": "Date/Time TST read", "field_kind": "text", "label": "Date/Time TST read", "pdf_field_name": "DateTime TST read_2", "pdf_field_type": "Text", "reading_order": 30 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 368.64, "t": 254.28, "r": 535.68, "b": 234.6 }, "text": "Read by", "field_kind": "text", "label": "Read by", "pdf_field_name": "Read by_2", "pdf_field_type": "Text", "reading_order": 31 }, { "page": 1, "type": "TEXT", "location": { "l": 313.44, "t": 246.48, "r": 367.68, "b": 232.32 }, "text": "Read by:", "reading_order": 32 }, { "page": 1, "type": "TEXT", "location": { "l": 70.56, "t": 226.08, "r": 438.24, "b": 210.72 }, "text": "Results in mm: ___ Interpretation: ā˜ Negative\nā–” Positive", "reading_order": 33 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 152.28, "t": 233.16, "r": 273.12, "b": 213.48 }, "text": "Results in mm", "field_kind": "text", "label": "Results in mm", "pdf_field_name": "Results in mm_2", "pdf_field_type": "Text", "reading_order": 34 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 357.96, "t": 226.44, "r": 375.48, "b": 211.44 }, "text": "Negative", "field_kind": "checkbox", "label": "Negative", "pdf_field_name": "Negative_2", "pdf_field_type": "CheckBox", "reading_order": 35 }, { "page": 1, "type": "TEXT", "location": { "l": 453.84, "t": 226.8, "r": 523.2, "b": 210.24 }, "text": "Positive", "reading_order": 36 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 455.04, "t": 225.84, "r": 472.44, "b": 210.96 }, "text": "Positive", "field_kind": "checkbox", "label": "Positive", "pdf_field_name": "Positive_2", "pdf_field_type": "CheckBox", "reading_order": 37 }, { "page": 1, "type": "TEXT", "location": { "l": 69.6, "t": 182.88, "r": 513.6, "b": 154.56 }, "text": "QuantiFERON Gold testing (recommended if immunized with BCG or a previous positive TST test):", "reading_order": 38 }, { "page": 1, "type": "TEXT", "location": { "l": 69.84, "t": 141.36, "r": 210.96, "b": 127.44 }, "text": "Results: ___ *", "reading_order": 39 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 114.84, "t": 148.56, "r": 201.24, "b": 128.88 }, "text": "Results", "field_kind": "text", "label": "Results", "pdf_field_name": "Results", "pdf_field_type": "Text", "reading_order": 40 }, { "page": 1, "type": "TEXT", "location": { "l": 69.6, "t": 112.56, "r": 365.04, "b": 98.4 }, "text": "*A copy of lab result must be included with this form.", "reading_order": 41 } ] } ]