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The "tuberculosis and syphilis report form" serves as an official document used to record and report test results for tuberculosis (TB) and syphilis. Originating from the State of Hawaii Department of Health, this form is crucial for tracking these significant public health concerns. It includes sections that capture personal information, clinical test details, and authentication by medical professionals. The structured format ensures comprehensive data collection, providing an effective means for the state to manage and prevent the spread of these infectious diseases. Its usage is mandated in specific scenarios, particularly when there is a need for official verification of an individual's health status.
Personal Information Section: Begin by filling in the personal details of the individual being tested. This typically includes full name, date of birth, address, and contact information, ensuring accurate identification.
Test Details for Tuberculosis: Enter specific information about the TB test, such as the type of test administered (e.g., skin or blood test), the date of testing, and the name of the medical provider. Incorporate detailed results, including any positive or negative findings.
Test Details for Syphilis: Similar to the tuberculosis section, provide details about the syphilis test. Include the type of test conducted, date, and results, along with any necessary confirmatory testing if the initial result is positive.
Medical Provider Signature: The form necessitates signatures from licensed medical providers to verify the authenticity of the test results. This section must be completed with the provider’s contact information and professional identification number.
The form is essential for several reasons:
This form is predominantly used by:


In Hawaii, where this form originates, specific regulations dictate when and how these tests should be administered:
The completed form can typically be submitted in the following ways:
By detailing these procedures and guidelines, users are informed of the form's purpose and requirements, ensuring they can effectively complete and submit the tuberculosis and syphilis report form.
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The information collected on this form is used to assist DoD physicians in making determinations as to acceptability of applicants for military service and
Jan 1, 2025 shingles, syphilis, or tuberculosis) are excluded from meeting SSI criteria. procedure finish time, report one Denominator for Procedure form
To report an immediately notifiable disease or condition, an outbreak among three or more persons or an unusual manifestation of any disease or.