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Home
About
Services
Home Care
Companion Care
Enhanced Pediatric Care
Personal Care & Support
Home Infusion – IV Therapy
Blog
Service Areas
Careers
Forms
Contact
Schedule Appointment
Initial Mantoux PPD Skin Testing
Name of Applicant
Date of Hire
MM slash DD slash YYYY
Please answer the following questions:
Have you ever had tuberculosis?
Yes
No
Have anyone close to you had tuberculosis?
Yes
No
Have you ever been exposed to tuberculosis?
Yes
No
Have you ever had a reaction to the TB test?
Yes
No
Have you had stomach or intestinal surgery?
Yes
No
Were you born in the continental United States?
Yes
No
Have you ever had BCG vaccination for TB?
Yes
No
How long ago? # of years
Yes
No
Is you immune system working well?
Yes
No
Are you taking steroids or cortisone?
Yes
No
Are you receiving radiation or chemotherapy?
Yes
No
Comments:
I understand that this test is required a s a condition of employment and potential side effects, which are possible as with any medication, have been explained to me. I am currently not pregnant or nursing a baby. I am in good health. I consent to the administration of the Mantoux PPD skin test and I understand that I must report back at the given date for the test to be read.
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Date
MM slash DD slash YYYY
Agency Representative
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MM slash DD slash YYYY
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