Tuberculosis (TB) Forms - Illinois Department of Public Health 2025

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The document is an Employee TB Test Form required by the Illinois School Code for employment candidates in Chicago Public Schools. It mandates that candidates must be free of tuberculosis, with a TB skin test performed within the last 90 days, and if positive, a chest x-ray must also be conducted within the same timeframe. The form requires documentation of test results and consent for information release from the examining physician.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the 'DATE PLACED' for your TB test. This is crucial as it indicates when the test was administered.
Next, fill in the 'DATE READ' field, which is when the results were interpreted. Ensure this date is within 90 days of employment application.
Record the 'RESULTS' of your TB skin test in millimeters (MM). If positive, remember to note that a chest x-ray must also be documented.
Provide your physician's 'MEDICAL LICENSE NUMBER' and 'STATE'. This verifies the legitimacy of your medical provider.
Print your name clearly in the designated area and ensure that your M.D. or D.O. signs the form.
Complete your address details including city, state, zip code, and telephone number for contact purposes.
Finally, if applicable, include a fax number for any further communication regarding your TB test results.

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Versions	Form popularity	Fillable & printable
2013	4.6 Satisfied (33 Votes)
2011	4 Satisfied (42 Votes)

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What are the forms of tuberculosis?

Types Pulmonary TB disease. Pulmonary TB disease affects the lungs. Extrapulmonary TB disease. Extrapulmonary TB disease occurs in places other than the lungs, including the larynx, the lymph nodes, the pleura, the brain, the kidneys, or the bones and joints. Miliary TB disease. TB meningitis. Drug-resistant TB disease.

What is a TB clearance letter?

This letter is to document that is free of communicable tuberculosis disease. He/she is free to participate in any activity including work, school, adoption, foster care, etc. - At this time there is no need for any further testing or treatment for this patient.

What happens in a TB screening?

TB screening involves the active identification of people at risk for TB disease. Populations or high-risk groups are screened by assessing symptoms and by using tests, examinations or other procedures that can be applied rapidly. TB screening is sometimes also referred to as active TB case finding. Tuberculosis: Systematic screening - World Health Organization (WHO) World Health Organization questions-and-answers item sy World Health Organization questions-and-answers item sy

What is a TB screening form?

To be completed by student. This document is a screening tool used to determine potential exposure to active Tuberculosis.

What is a TB certificate?

Prior to applying for your visa, you will require a valid screening certificate from an approved clinic, confirming that you are free from lung TB . If you are found to no longer have lung TB , the certificate can then be issued, and you should include it with your visa application.