Life tb evaluation form 2026

1. Click ‘Get Form’ to open the life tb evaluation form in the editor.
2. Begin by entering the resident's last name, first name, middle/maiden name, address, city, state, date of birth, and zip code in the designated fields.
3. Indicate the date of the most recent Mantoux tuberculin skin test and check the box if previously positive or if any information is unknown.
4. If applicable, note mm of induration and check if exhibiting TB-like symptoms. If the TB skin test result is 10 mm or greater (or 5 mm for HIV-infected individuals), proceed to answer additional questions.
5. Fill in the date of the last chest x-ray evaluation and indicate whether it suggests active TB by selecting 'Yes' or 'No'.
6. Answer whether sputum smears were collected and analyzed for Acid Fast Bacilli (AFB) and provide details on whether three consecutive smears were negative for AFB.
7. Finally, based on your responses, determine if the individual is free of communicable TB and complete the evaluator's information including name, signature, phone number, and date completed.

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