Appendix C.11 - Sample FGP-SCP TB Test Form 2026

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The document is a sample TB Test Form for the ABC Foster Grandparent/Senior Companion Program, outlining the requirements for tuberculosis testing for volunteers. It includes sections for personal information, test results, and provider information, as well as a separate screening form for those with a history of positive TB tests. The document emphasizes that while TB tests are not mandatory by Senior Corps, they may be required by certain sponsoring agencies.

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Click ‘Get Form’ to open the Appendix C.11 - Sample FGP-SCP TB Test Form in the editor.
Begin by entering your personal information in the designated fields, including your name, date of birth, address, and phone number.
If you have had a positive TB test previously, skip the TB test section and proceed to the next page. Otherwise, fill in the PPD Test Date and Date Read.
Indicate the number of millimeters of induration and provide results/interpretation in the respective fields.
Complete the provider information section by entering the health professional's signature, hospital/clinic/organization name, and date.
If applicable, fill out the Positive Tuberculosis (TB) Test Screening Form on the second page with relevant details regarding past positive tests and any follow-up actions taken.

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