PPD SKIN TEST RECORD FORM
PATIENT INFORMATION
Name: _____________________________________________________________________
Address: ___________________________________________________________________
City/Town: ______________________ State: ________________ Zip: _________________
Telephone: ____________________________ |
________________________________ |
Home |
Cell or Work |
STUDENT INFORMATION
Student ID #: __________________________ Class of: _____________________________
SKIN TEST INFORMATION
Administrator Name: __________________________________________________________
Date/time Administered: _______________________________________________________
Arm on which Administered: ___________________________________________________
Manufacturer of PPD Solution: __________________________________________________
Expiration Date of PPD Solution: ________________________________________________
Lot #: __________________
RESULTS
Induration: ___________________mm Date/time of Reading: ____________________
Comments and Adverse Reaction(s), if any: ______________________________________
__________________________________________________________________________
Printed Name and Title (MD/RN/MA) of Reader: __________________________________
HealthCare Provider Signature:____________________________ Date:_____/_____/______
Updated 11/13 OR