Dear Physician/Health Care Provider:
State health regulations require that all applicants for school-based fieldwork (Practicum and Student
Teaching) provide written proof of a current, negative PPD (Mantoux) Tuberculin Test. Please note that a Tine
or Monovac Test may not be substituted for the PPD Test. The test can be performed by your personal
physician or at any health clinic. The results must be reported as positive or negative, recorded in millimeters
(mm), and certified by a health care provider.
Applicants must be able to provide proof of a negative tuberculin test that was administered within 12 months
by the beginning of the semester for the enrolled school-based field work (Practicum and/or Student Teaching)
course. Applicants should retain a copy of test results for future use.
IMPORTANT NOTICE ABOUT THIS DOCUMENT:
For identification, the health care provider signing this certificate should also submit one of the
following:
1. signed voided prescription form
2. signed letterhead with patient’s name and date of office visit
3. office stamp with name of provider’s office and address
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PPD (MANTOUX) TUBERCULIN SKIN TEST
(Tine or Monovac is not acceptable)
Student ID: __________
______________________________________________________________________
Last Name First Name M.I.
Date administered: Date read:
PPD (Mantoux) Test Result: Negative Positive mm induration (if no induration, mark “0”)
Name of Facility: ___________________________________________
Name of Health Care Provider: ______________________________________
Signature of Health Care Provider:
Please return the signed certificate to the applicant, or mail directly to:
Keira Potter, Compliance Manager
Office of Clinical Studies
Wilmington University
3282 N. DuPont Hwy.
Dover, DE 19901
Telephone: (302) 342-8608
Fax: (302) 734-1331
E-mail:
keira.m.potter@wilmu.edu
