Health Screening Management Team
Faculty of Health Sciences, HSC 2E5A
Hamilton, Ontario
L8S 4K1
(905) 525-9140 x22249
FAX: (905) 528-4348
Previous Positive TB Skin Testing Form
If you have a record of a positive TB skin test recorded on your Level 1 Health Screen, you
do not require a TB skin test. You are asked to review the signs & symptoms of TB below. If
you do not have any of the signs & symptoms, please fill out the below form and deliver to
your program office or the health screening management office. If you have any of the
signs or symptoms, follow up with your physician or the Student Wellness Centre, x27700
to be managed using current guidelines. A reminder that it is your ethical and professional
obligation to inform the Assistant Dean of your program of any infection of Tuberculosis
-
Cough
Hemoptysis (coughing up of blood)
Night Sweats
Fever
unexplained weight loss
This is to verify that I have a positive TB Skin Test and negative chest x-ray on record with
the Faculty of Health Sciences, and do not have any of the signs or symptoms stated above.
Name: ______________________________
Student Number: _____________________
Date: ______________________________
Program: ____________________________
Signature: ___________________________
The information gathered on this form is collected under the authority of the McMaster University Act, 1976. The information is used for the
academic, administrative, employment-related, financial and/or statistical purposes of the University including, but not limited to, admissions;
registration and maintaining records; awards and scholarships; convocation; provision of student services, including access to information
systems; alumni relations; and disclosure to or on behalf of the applicable McMaster student government. This information is protected and is
being collected pursuant to section 39(2) and section 42 of the Freedom of Information and Protection of Privacy Act of Ontario (RSO 1990).
Questions regarding the collection or use of this personal information should be directed to the University Secretary, Gilmour Hall, Room 210,
McMaster University.