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TB Test Results Entry Form Template

Streamline Your TB Test Documentation Effortlessly

Recording TB test results can be challenging, but this template simplifies the process for healthcare providers. With the TB Test Results Entry Form, you can efficiently track and manage patient outcomes, ensuring clear communication and accurate documentation. It offers key benefits, including easy data entry, improved organization of test results, quick access to patient history, and enhanced reporting capabilities-all designed to support your workflow. Experience the ease of using this live template.

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Patient full name
Date of birth
Patient ID or record number
Primary phone
Secondary phone (optional)
Test type(s) performed
Tuberculin skin test (TST/Mantoux)
IGRA - QuantiFERON-TB Gold Plus
IGRA - T-SPOT.TB
Other
Please Specify:
BCG vaccination history
Yes
No
History of prior positive TB test
Yes
No
Reason for testing
Employment or school requirement
Contact of a TB case
Healthcare worker screening
Pre-immigration or visa
Symptoms suggestive of TB
Pre-biologic or immunosuppressive therapy
Prefer not to say
Other
Please Specify:
TST placement date
TST reading date
Induration (mm)
TST interpretation
Positive
Negative
Borderline
Invalid or not read
Not performed
IGRA specimen collection date
IGRA quantitative value (e.g., IU/mL or SFCs)
IGRA result
Positive
Negative
Indeterminate
Borderline
Not performed
Current symptoms (select all that apply)
Cough longer than 3 weeks
Fever
Night sweats
Unintentional weight loss
Hemoptysis
None
Prefer not to say
Risk factors (select all that apply)
Chest X-ray performed
Yes
No
Chest X-ray result
Normal
Abnormal suggestive of active TB
Abnormal not suggestive of TB
Pending
Not performed
Sputum testing performed
Yes
No
Sputum result
AFB smear positive
AFB smear negative
NAAT positive
NAAT negative
Culture positive
Culture negative
Pending
Not performed
Clinical classification
Latent TB infection
Active TB disease
No evidence of TB
Undetermined or pending
Treatment initiated
Yes
No
Regimen started (select all that apply)
Isoniazid (INH)
Rifampin (RIF)
Rifapentine + Isoniazid (3HP)
Isoniazid + Rifampin (INH+RIF)
Not applicable
Other
Please Specify:
Case reported to public health
Yes
No
Ordering clinician name
Facility or clinic name
Provider phone
Date of entry
Signer name
Signature date
I confirm the information provided is complete and accurate to the best of my knowledge.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
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Paper art illustration featuring a TB test results entry form template for FormCreatorAI article

When to use this form

Use this template to record PPD or IGRA results for employees, students, and patients who need proof for work, school, or care. It helps nurses, HR, and clinic admins capture the test date, method, induration in mm, interpretation, provider details, and next steps. Use it after reading a Mantoux test at 48-72 hours or when entering a lab IGRA result. You can generate a clean record for files or pair it with the TB Skin test results form for a printable summary. For programs that ask for proof of screening, attach the record to a Medical card application form. If your facility must notify public health when results are positive, you can route details to your reporting process.

Must Ask TB Test Results Entry Questions

  1. What test type was performed (PPD/Mantoux or IGRA)?

    This defines how you should read and interpret the result. It also guides next steps, such as whether a chest X-ray is needed.

  2. What is the test administration date and time, and who performed it?

    These details validate the 48-72 hour PPD reading window and lab turnaround expectations. Listing the performer adds accountability and a contact for clarifications.

  3. For PPD, what is the measured induration in millimeters at 48-72 hours?

    Exact millimeters, not redness, determine positive vs negative by risk category. Recording the time window confirms the reading was valid.

  4. What is the final interpretation (negative, positive, or borderline) and which risk factors were applied?

    Stating the call and criteria shows how you reached the decision. This helps HR and schools apply policy consistently.

  5. What follow-up actions are required and how should we contact you?

    Clear next steps (for example, repeat testing or imaging) reduce delays and missed care. If you must notify public health for positives, document outreach using the Contact tracing form.

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