TB Clearance Process Requirements for Students/Staff who are
New PPD Skin Test Convertors
Definition: New Convertor is a term applied to those persons who had prior history of negative Tuberculosis
(TB) skin tests but their most recent one is now positive.
Steps Required for TB Clearance
Once it has been determined that a student is a new convertor, the following steps are required in order to
document and provide TB clearance before the student can be cleared to return to class/work/clinical:
1. Immediate referral to a licensed healthcare provider for health evaluation.
2. AP/Lat Chest x-ray to aid in the exclusion of pulmonary TB (submit copy of the chest x-ray radiology
report).
3. Completion of a TB Symptoms Health Screening Checklist (attached)
4. TB Skin Test New Convertor Clearance Form (attached) completed and signed by student and
healthcare provider.
Upon completion, the TB skin test new convertor clearance form, chest x-ray radiology report and completed
TB symptoms health screening checklist must be given to the Student-Employee Health Coordinator (SEHC).
The SEHC will then notify the Dean that the student is cleared to return to usual duties.
Notification of Removal From Class /Clinical
A student with a newly positive Tuberculosis Skin Test (TST) shall be removed from their assignment(s) until
they have been seen, evaluated and cleared by a licensed healthcare provider. The student will be advised on
what they must do in order to be allowed to return to their assignment.
Removal: The College Dean, and/or Clinical Dean shall be notified by the Student-Employee Health
Coordinator of this requirement for removal by telephone or in person only. Discussion may be required on
determining when the student has to be removed, e.g., student has exam in the next day or two. In order to
protect the health of our patients and clinical staff, the student should be relieved of all clinical assignments
immediately.

Every effort will be made to expedite the health clearance process so that the student can return to
their assignment as quickly and safely as possible.
Return: Once the student is cleared to return to their assignment, the Student-Employee Health Coordinator
will notify, by phone or in person only, the College Dean or Clinical Dean of the clearance to return.
Once you are considered to have a positive TST, it is recommended that you do not receive them again. A TB
Symptoms Health Screening Checklist form and chest x-ray are recommended for all future TB clearance.
TB Skin Test New Convertor Clearance Form
STUDENT
I, _______________________ have been told that I have been diagnosed with
latent tuberculosis infection. My tuberculin skin test was positive at ____mm
and/or I had a positive quantiferon test on ___/___/___ showing that I have been
infected with the tuberculosis bacteria.
____ I understand I must be seen and evaluated by a healthcare provider in order
to obtain TB clearance.
____ I will provide the Student-Employee Health Office with documentation from
my healthcare provider regarding my TB clearance on ___/___/___ (needs to be
completed within 5 days).
____________________ __________________ __________ __/__/__
Student Name
Student Signature
ID#
Date
HEALTHCARE PROVIDER
____ I have reviewed the Tuberculosis Health Screening Checklist completed by
the student.
____ I have reviewed the student’s chest x-rays.
____ I have discussed treatment options with the student.
____ I have seen, evaluated, and determined that this student does not have
active pulmonary tuberculosis disease.
Comments: _____________________________________________
___________________
___________________
___/___/___
Healthcare Provider Name
Healthcare Provider Signature
Date
TB Symptoms Health Screening Checklist
Date: ________________________
Student/Employee ID # @____________________
College: COMP
Dental
MSMS
Nursing
Campus: Pomona
Optometry
Name______________________________________________
PT
PA
Lebanon, OR
Pharmacy
Grad. Year: _______
Podiatry
Vet Med
Birth Date___________________________
Address _________________________________________City _______________________ Zip Code_________
Telephone Number ______________________________
Date of last PPD _____________________________________
Date of Quantiferon gold serum test: _____________________
Date of Last Chest X-Ray:_____________
PPD Results ______________ MM
Results: __________________
Results: ______ Positive for TB
_______ Negative for TB
1. Have you ever been told you have active tuberculosis?
( ) Yes
( ) No
2. Have you ever taken INH or any other anti-TB drug?
( ) Yes
( ) No
If yes, list names:
3. Date and duration of medication regime
(months)
4. Have you ever had BCG Vaccination? ( ) Yes ( ) No If yes, when? ________________________________
5. During the past year have you noticed:
 Unexplained weight loss? ...................
( ) Yes
( ) No
 Decrease in your appetite? .....................
( ) Yes
( ) No
 Cough not associated with cold or flu? ......
( ) Yes
( ) No
 Increase in AMOUNT of Sputum? ..........
( ) Yes
( ) No
 Change in COLOR of Sputum? ..........
( ) Yes
( ) No
 Change in CONSISTENCY of Sputum? .......
( ) Yes
( ) No
 Blood Streaked Sputum?......
( ) Yes
( ) No
 Night sweats? ........
( ) Yes
( ) No
 Unexplained low grade fever? .....
( ) Yes
( ) No
 Unusual tiredness or fatigue? ......
( ) Yes
( ) No
 Swelling of lymph nodes? ...........
( ) Yes
( ) No
 Have you had contact with a family member or partner who has been diagnosed with tuberculosis?
( ) Yes
( ) No
 Have you or a member of your family been exposed to someone who is immune compromised?
( ) Yes
( ) No
Explain any “Yes” answers above: _________________________________________________________________
_____________________________________________________________________________________________
List any on-going medical problem(s):
Evaluation :
Signature of Reviewer:_____________________________________________________
________ No further action needed
_______Chest X-Ray Requested
Date
______ Further Evaluation Needed
Must be reviewed by licensed healthcare provider if any “yes” answers
TB Symptoms Questionnaire 7-22-10; Rev 4-7-11; 8-12-11; 9-7-11; 6-18-15