Latent TB Infection: Diagnosis Sample Documentation Forms

Latent TB Infection: Guide for Diagnosis and Treatment

Diagnosis

Sample Documentation Forms

Record of TB Skin Test

To Whom It May Concern:

The following is a record of Mantoux tuberculin skin testing:

Name:______________________________________________

Date of birth: ________________________________________

Date and time test administered: __________________________

Administered by: _____________________________________

Manufacturer of PPD:__________________________________

Expiration date: __________________ Lot Number:__________

Date and time test read: ____________ Read by: ____________

Date:______________________________________________

Results (in millimeters of induration)_________________

Record of Interferon-Gamma Release Assay for TB

To Whom It May Concern:

The following is a record of IGRA results:

Name:___________________________________________________

Date of birth:______________________________________________

Type of test:________________________ Date:__________________

Laboratory:_______________________________________________

Qualitative result:____________________ Nil (IU IFN-γ):___________

Mitogen (IU IFN-γ): ___________    M. tb antigens (IU IFN-γ):______