PPD (Tuberculosis Skin Test)
Consent Form
Salt Lake County Health Department promotes and protects community and environmental health
saltlakehealth.org
I, _________________________________, give the Salt Lake County Health
printed name
Department permission to administer and read, within 72 hours, a PPD (intradermal
tuberculosis skin test) for, _________________________, my unaccompanied 16 or
teen’s name
17-year old.
I understand that a positive PPD may indicate that the teen has been exposed to
bacteria that cause tuberculosis (TB), but does not necessarily mean he or she has
active TB. A tuberculosis diagnosis requires additional testing and consultation.
____________________________________________ ______________
Parent or Guardian Signature Date
click to sign
signature
click to edit
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