TUBERCULIN CERTIFICATION
 This form is for use by Kelly Healthcare or Kelly Government Solutions only.
 Kelly Representative: If administering this form in person, complete Section 1 and indicate in Section 3 the type of TB screen. If administering
electronically, provide employee branch address and type of TB screen so they can complete. Distribute signed copies appropriately.
Employee: You must be certified free of infectious tuberculosis (TB) by a medical provider as requested by Kelly’s customer or for
positions with direct patient contact. TB screening is not necessary if you provide a signed medical provider’s form that is dated within
the last 12 months and confirms a negative result.
If you have had positive TB skin tests, or have the BCG vaccination and have medical documentation of a negative Chest X-Ray dated
within the past 6 months, complete section 2 and the symptom survey. If your TB medical documentation (Chest X-Ray) is dated
greater than 6 months, take this form and your TB medical documentation to the medical provider to certify that you are free of
infectious disease. You will be asked to complete the Symptom Survey (below) annually.
If you cannot provide the above documentation, you must receive TB screening. If the result of the pre-placement screening is
positive, it is your responsibility to obtain confirmation screening and medical attention as prescribed by the medical provider. When
you are certified free of infectious disease, return this completed form to Kelly Services.
Section 1: Kelly Information
Kelly Representative’s Name
Branch Telephone No.
Date (MM/DD/YY)
Branch Fax No.
Branch Address
Section 2: Employee Acknowledgement (Employee: Sign and return to your Kelly representative for further instruction.)
I provided Kelly Services TB screening results indicating a negative TB skin test result dated within the last 12 months.
I have not been TB screened or have expired documentation. I understand that certification from a medical provider that I am
free of infectious disease is required prior to starting a position that requires TB screening and on an annual basis.
I have had a previous positive TB skin test or BCG vaccination.
 Pre-placement:
I understand that certification from a healthcare provider stating that I am free of infectious
tuberculosis is required prior to starting a position that requires TB screening if my medical documentation is dated greater
than 6 months.
I have provided Kelly Services TB screening results indicating a negative Chest X-Ray dated within the
past 6 months and have completed the Symptom Survey below.
 Annually: I agree to complete the following Symptom Survey and will immediately contact my Kelly representative if I
begin to experience any of these symptoms.
Symptom Survey (Indicate if you have persistently experienced the following symptoms within the past year.)
Coughing blood
Coughing for more than two weeks
Excessive fatigue or loss of energy
Yes
Yes
Yes
No
No
No
Night sweats (soaks your bedding)
Unexplained and/or recurrent fever
Unexplained weight loss
No
No
No
Social Security No. (Last four digits only)
Date (MM/DD/YY)
Employee Printed Name
Yes
Yes
Yes
Employee Handwritten Signature (Required AT HIRE)
Employee Signature (Electronic* - Acceptable for ANNUAL requirements)
*If you are submitting this form electronically, type your name on the Employee Signature line above and check the box to the
right next to “I agree.” This is your electronic signature. By electronically signing this form, you agree that you have reviewed
this entire form and agree to all the terms contained in it.
I agree.
Section 3: Medical Provider Certification
Please accept this form as authorization to conduct the TB screening indicated below. Upon completion, please fax this form and
your clinic’s documentation to Kelly Services.
One-Step Skin Test
Date Administered:
Date Read:
Result:
Positive
Negative
Two-Step Skin Test
Date Administered:
Date Read:
Result:
Positive
Negative
Confirmation Screening or Review of Medical
Documentation (e.g., Chest X-Ray)
Type of Screening:
Date Read:
I certify that the above named individual is free from infectious disease.
Medical Provider Printed Name
Result:
Positive
Negative
Expiration Date (12 months from date screening was administered)
Date (MM/DD/YY)
Medical Provider Signature
ORIGINALKelly Services
© 2012 Kelly Services, Inc.
Date Administered:
COPYMedical Provider
An Equal Opportunity Employer
COPYEmployee
e3799
R2/12