CSP Nursing Student
Tuberculosis Status – Initial
Student Full Name
Student Date of Birth
Student Address, City, State, Zip
Tuberculosis: Student - tell your provider if you have received the BCG vaccine and if
so, when you received it. (This vaccine is only given outside of the United States.) Also
tell your provider if you have a history of a positive TB test.
Requirement: Negative TB blood test (QuantiFeron®-TB GOLD [QFT-GIT] or T-SPOT® TB Test)
completed within the last year.
TB Blood Test
Type (circle)
Date
Result (positive or negative)
QuantiFeron®-TB GOLD or
T-SPOT®
---OR—
Requirement: Negative (0-<5 mm) two-step purified protein derivative (PPD) completed within
the last year. The Center for Disease Control and Prevention recommends the first test be
administered and then evaluated (read) 48-72 hours later, no earlier and no later. A minimum of
7 days after and maximum of 21 days after the administration of the first test, the second test
can be administered. The second test is evaluated 48-72 hours later
Tuberculin Skin Test (PPD) – Two Step
Step
Date Administered
Result (positive or negative)
Step-1
Step-2
1
---OR FOR POSITIVE PPD ONLY-For students with a past positive PPD, a negative chest x-ray (no evidence of active pulmonary
disease) is required once. Chest x-rays are only acceptable if taken as a follow up to a previous or
current positive TB skin test.
Chest X-ray
Date
Result
Date
Tuberculosis Symptoms Questionnaire Completed (next page)
Result (negative/low risk –or- positive/risk of TB)
CSP Nursing Annual Tuberculosis Questionnaire (required only if indicated)
Check box if not applicable (chest xray is not required)
The Annual Tuberculosis (TB) Questionnaire is used to evaluate your current TB status. We cannot utilize
the tuberculin skin test (PPD or Mantoux), because you have a positive reaction to the test. A positive skin
test means that sometime during your life you came into contact with tuberculosis or have had a
vaccination to prevent you from contracting tuberculosis. It does not mean that you have TB now.
In the past, yearly chest x-rays were performed; however, recent studies show that they are unnecessary.
Instead, this health survey will assist your provider to monitor possible TB Symptoms. TB symptoms can
progress slowly and/or mimic other diseases. You can develop symptoms of TB a few weeks after
contracting the bacteria – or not until years after the initial infection. This questionnaire targets some of
the most common symptoms. Please familiarize yourself with them. You are the first to know when you
are not feeling well and may have TB symptoms.
Tuberculosis Health Check Survey
Have you ever experienced any of the following symptoms NOT associated with a specific illness (i.e. flu
or cold) and lasting 3 weeks or longer?
Cough
Yes
No
Hoarseness
Yes
No
Blood Streaked Sputum (phlegm)
Yes
No
Loss of Weight (unplanned/unexplained)
Yes
No
Night Sweats
Yes
No
Fever/chills
Yes
No
Anorexia (loss of appetite)
Yes
No
Unexplained Fatigue (tiredness)
Yes
No
Chest Pain
Yes
No
This authorization will expire one year from the dated signature below.
_____________________________________________ ______________________________________
Student Name Printed
Student Signature
Date
2
Verification of TB Status by Healthcare Provider or Nurse
All tuberculosis status dates above are hereby certified and all other medical records of this
student are on file at the physician/provider’s office.
Signature of Provider or Nurse
Name of Provider or Nurse – Please print
Date
Credentials – Please Print
Clinic Name and Address
Clinic Telephone Number
3