1 TB Screening Form

  OMB Control No: 0970-XXXX

Expiration date: XX/XX/XXXX

Supplemental TB Screening
General Information (to be completed by shelter staff)
Child	Last name:			First name:
	DOB:	A#:					Gender:
Healthcare Provider or Health Dept.	Name:		Phone number:			Clinic/Practice:
	Street address:		City/Town:			State:		Date of visit: ____/____/______
Program	Name of program staff with child:				Program name:

Medical Info (to be completed by provider’s office or health dept.)
PPD/Tuberculin skin test (TST):	Date applied: ____ / ____ / ______				Date read:____ / ____ / ______
	Result: ________ mm				Interpretation:		Positive		Negative
TB blood test (Interferon-Gamma Release Assay [IGRA]):	Date drawn: ____ / ____ / _____
	Test Type:	QuantiFERON®-TB Gold In-Tube test (QFT-GIT)						T -SPOT®.TB test (T-Spot)
	Result:	Positive	Negative			Borderline/ Equivocal/ Indeterminate
Chest x-ray:	Date: ____ / ____ / _____
	Findings:	Normal	Abnormal
TB Determination:	Negative for TB condition			Latent tuberculosis infection (LTBI)						Active TB suspected
Additional Information

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is estimated to average 2 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.