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Tuberculosis screening form pdf

Virginia tb screening form 2026

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The document is a tuberculosis screening report that evaluates an individual's risk and status regarding tuberculosis. It includes information on tuberculin skin test results, chest x-ray findings, and the absence of symptoms suggestive of active tuberculosis. The report concludes whether the individual is free of communicable tuberculosis or requires further evaluation.

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Click ‘Get Form’ to open the Virginia TB Screening Form in our editor.
Begin by entering the date at the top of the form. This is essential for record-keeping.
Fill in your name and date of birth in the designated fields. Ensure accuracy as this information is crucial for identification.
In the section labeled 'TO WHOM IT MAY CONCERN', specify the name of the health department or facility that conducted your evaluation.
Indicate whether a tuberculin skin test (PPD) is indicated by checking the appropriate box based on your symptoms and history.
If applicable, provide details regarding any chest x-ray results, including dates and findings, ensuring you check the correct box for either normal or abnormal results.
Finally, have a qualified MD or Health Department Official sign and date the form, along with their address and phone number.

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virginia tb screening form

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