WEBER STATE UNIVERSITY SCHOOL OF NURSING ANNUAL PPD (TB) TEST Print Name ___ Campus__________________ Please have this form completed by your healthcare provider or local health department for your annual PPD (TB) test. PPD (TB) test must be current through May 2014. If your PPD expires prior to May 2014, you will need to obtain a new PPD (TB) test. PPD (TB) test date . Results were negative _______mm Results were positive _______ mm. If positive, see below. Signature________________________________________________________________ Facility test given at _______________________________________________________ If you are unable to have a PPD (TB) test (because of prior positive reading or BCG vaccine), please see your healthcare provider for further treatment. TO BE FILLED OUT ONLY IF YOU HAD A POSITIVE PPD (TB). If you are experiencing any of the symptoms below or have a history of a positive PPD with or without obvious signs/symptoms of tuberculosis, you are required to see your healthcare provider to obtain a chest x-ray. Unless otherwise determined by your healthcare provider, a chest x-ray is required annually for positive PPD. Have you had any of the following: Yes No Yes No Yes No Night Sweats Loss of appetite Weight Loss Fatigue Fever Chronic Cough Blody Sputum Cough that causes your chest to hurt Malaise (generally not feeling well) Last Chest X-Ray date __________________________________________
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