Southwest Virginia Community College Nursing Program
Tuberculosis Screening Requirement Form
Name: __________________________________________________Student ID #: _________________
Student must provide proof of negative TB status by submitting one of the options below:
Option 1: Two-Step TB Skin Test
FIRST STEP OF THE TWO-STEP TB SKIN TEST (TST)
Date Test Given (mm/dd/yyyy):
Site: ☐Left Forearm ☐Right Forearm
Review & Document Results after 48-72 hours
Date Test Read (mm/dd/yyyy):
Interpretation: ☐Negative ☐Positive
o If positive result- consider TB infected, no second TST needed; proceed to Option 3 to evaluate for TB disease
o If negative result- a second TST is required 7-21 days after first TST is read
Measurement of Induration (in millimeters)______mm
SECOND STEP OF THE TWO-STEP TB SKIN TEST (TST) Administer 7-21 days after first TST is read
Date Test Given (mm/dd/yyyy):
Site: ☐Left Forearm ☐Right Forearm
Review & Document Results after 48-72 hours
Date Test Read (mm/dd/yyyy):
Interpretation: ☐Negative ☐Positive
o If positive result- consider TB infected and proceed to Option 3 to evaluate for TB disease
o If negative result- consider person not infected
Measurement of Induration (in millimeters)______mm
Option 2: TB Screening Blood Test
INTERFERON-GAMMA RELEASE ASSAY (IGRA)-QUANTIFERON OR T-SPOT:
Date Test Given (mm/dd/yyyy):
Interpretation: ☐Negative ☐Positive
o If positive, consider TB infected and proceed to Option 3 to evaluate for TB disease
o If negative, consider person not infected
Option 3:
If a person has a previously documented positive TB screening test or a documented diagnosis of TB or Latent TB
Infection (LTBI) in the past, provide documentation of previous negative chest x-ray or negative blood test AND a
completed SWCC Nursing Tuberculosis Symptom Screening Questionnaire. This questionnaire/review of symptoms
should be completed with your healthcare provider. A repeat Chest x-ray is only required if symptoms develop.
CHEST X-RAY
Documentation that the Chest x-ray was performed to rule-out tuberculosis due to a positive TB skin test, IGRA
blood test or due to the development of signs or symptoms of tuberculosis must be in the chest x-ray report or
comments.
Date of Chest x-ray (mm/dd/yyyy):
Interpretation: ☐Normal ☐Abnormal
SWCC Nursing Tuberculosis Symptom Screening Questionnaire reviewed and completed with student ☐ Yes
Healthcare Provider Signature:
