Initial Two-Step Tuberculin Skin Test Report Form

College of Saint Benedict/Saint John’s University – Department of Nursing

The deadline for submission is August 15. Please email a scanned copy to dbaloun@csbsju.edu and keep a copy
for your records.
Student Information (please print)

________________________________________
Williams ______________________________
Elijah
Last Name First

Clinic Information

CVSMC IL3 MINUTECLINIC IL59859

________________________________________ Rockford,IL
______________________________ 815-543-6404
____________________
Clinic Name City, State Phone

Please note: If the student has recently traveled to a TB high-risk area, he/she must complete a TB Symptom
Screening Form by August 15. The two-step PPD and this form can then be completed 8-10 weeks after
returning to the U.S.

 Two-step PPD (Mantoux)

NOTE: QuantiFERON blood test, tine, or monovac are not acceptable.
STEP 1:
02/05/2023
Date Given: _______________
Dr Ryan Smitch
Signature/Title: ___________________________________
MD

02/08/2023
Date Read: ________________ Dr Ryan Smitch
MD
Signature/Title: ___________________________________

0.05
Step 1 Results: _____mm Interpretation:  Negative  Positive
* Results must be read within 48-72 hours by trained personnel.

STEP 2:
Date Given: _______________
02/10/2023
Dr Ryan Smitch
Signature/Title: ___________________________________
MD

Date Read: ________________

02/13/2023 Dr Ryan Smitch
MD
Signature/Title: ___________________________________

0.04
Step 2 Results: _____mm Interpretation:  Negative  Positive
* Results must be read within 48-72 hours by trained personnel.

 Previous or current positive PPD or received BCG

A chest x-ray is required within two years and screened for absence of active TB symptoms.

Chest x-ray date: __________________ Results:  Negative  Positive

Medical Treatment Plan: ____________________________________________________

Student  can  cannot participate in providing patient care in all clinical areas.

Provider Signature/Title: __________________________________________________

This information is strictly CONFIDENTIAL and is used to comply with contractual requirements of clinical agencies. Information
supplied will become a part of your health record; it will not influence your standing at the college, and it will not be released to
anyone except by your written authorization.