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# Record of Tuberculosis Screening: Two Step

Student Name: ___ DOB: ___

Office Stamp/Address & Phone Number



Type of Screening (check one):

Tuberculin Skin Test (TST)

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.

## Step 1:

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



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.