Butte College
Health Statement______________________________________
Must be completed in English by a doctor or health practitioner. Please type in your information, print, sign, and submit.
Note: If you have received the Bacillus Calmette–Guérin (BCG) vaccination you may provide proof of inoculation.
APPLICANT NAME: _____________________________________________________________________________
Last Name (Family) First Name (Given) Middle Name
Tuberculosis (TB) Skin Test Date: ________________
TB Skin Test Result: Negative Positive
(month/ day/ year)
To Physician: Please comment on general physical condition of student applicant. Explain any condition that may affect travel or
living in the U.S. If TB test is positive, please explain result of follow-up chest X-ray, patient’s condition and treatment
.
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Physician Certification
I certify that all statements on this form are true and complete.
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Physician Name & Signature Date (month/ day/ year)
