Neway Directions, Inc. 6400 Gisholt Drive, Suite 102 Madison, WI 53713

TB Screening Neway Directions, Inc. 6400 Gisholt Drive, Suite 102 Madison, WI 53713

Name: ______

Documentation of TB Skin Test

Step 1 Step 2

0.1 cc 5TU Aplisol (or other approved solution) 0.1 cc 5TU Aplisol (or other approved solution) administered intradermally on R/L administered intradermally on R/L (circle one) forearm on ___/___/____ (circle one) forearm on ___/___/____ Name of solution: ______Name of solution: ______Manufacturer:______Manufacturer:______Lot #: ______Exp. Date: ___/___/____ Lot #: ______Exp. Date: ___/___/____

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Signature and title of person administering skin test Signature and title of person administering skin test x Please read result on ___/___/____ x x Please read result on ___/___/____ SELF READS WILL NOT BE ACCEPTED. SELF READS WILL NOT BE ACCEPTED. Results Results ______mm induration* ______mm induration* Date read: ___/___/____ Date read: ___/___/____

______Signature and title of person reading skin test Signature and title of person reading skin test * mm induration must be documented, “negative” not * mm induration must be documented, “negative” not acceptable acceptable

Classifying the Tuberculin Reaction > 5 mm is positive in > 10 mm is positive in > 15 mm is positive in  Persons known to have or suspected  Persons with certain medical  All persons with no known risk of having HIV infection conditions, such as diabetes, chronic factors for TB  Close contacts of a person with renal failure, malignancy, infectious TB immunosuppressive therapy,  Persons who inject drugs (if HIV silicosis, and being 10% or more status unknown) below ideal body weight (excludes  Persons whose chest x-rays are HIV infection) consistent with old, healed TB  Persons who inject drugs (if HIV status negative)  Foreign-born persons from areas where TB is common (such as Asia, Africa, Latin America)  Medically underserved, low-income populations, including high-risk racial and ethnic groups  Residents of long-term care facilities  Locally identified high-prevalence groups (e.g. migrant farm workers or homeless persons)  Health care workers who provide services to any of the above listed high risk groups

JHB/JMP 4/10