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TB Skin Test Results Form Template

Efficiently Record and Manage TB Test Results

Tracking TB skin test results can be a challenge, especially when you need accurate documentation for employment or health compliance. This template is designed for healthcare professionals and organizations that require a dependable and clear method for recording Mantoux test results. With the ability to streamline patient data collection, ensure WCAG-aligned accessibility, and easily print or share results, you can improve your workflow, maintain compliance, and enhance your record-keeping process. Explore how this straightforward template can simplify your TB testing documentation.

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Patient full name
Date of birth
Patient ID / Medical record number
Phone number
Date of TST placement
PPD manufacturer
PPD lot number
Dose / volume administered (e.g., 0.1 mL, 5 TU)
Injection site
Left forearm
Right forearm
Other location
Date of reading
Induration size (mm) (enter 0 if none)
Reading clinician name
Interpretation
Negative
Positive
Not read/Invalid
TB risk factors present (select all that apply)
Recent close contact with active TB case
HIV infection or immunosuppression
Chest X-ray findings suggestive of prior TB
Organ transplant recipient or on TNF-alpha inhibitors
Travel or residence (>=1 month) in high TB prevalence area
Healthcare or lab work with TB exposure risk
Injection drug use
None of the above
BCG vaccination history
Yes
No
Unknown
Current symptoms (select all that apply)
Cough longer than 2 weeks
Fever
Night sweats
Unexplained weight loss
Coughing up blood (hemoptysis)
None of the above
Actions taken today (select all that apply)
Chest X-ray ordered
IGRA blood test ordered
Referral to TB clinic
Prophylactic therapy discussed
Treatment initiated
Return visit scheduled
No further action needed
Patient notified of result
Yes
No
Provider electronic signature (type full name)
Date of attestation
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Paper art illustration depicting a TB skin test results form for FormCreatorAI article

When to use this form

Use this template when you need to document a Mantoux (PPD) reading for employment clearance, school admission, volunteer onboarding, or annual healthcare worker screening. It suits clinics, employee health, student health, and mobile outreach. You will capture placement date and time, forearm site, induration in mm at 4872 hours, interpretation, and provider signature, so reviewers can make fast decisions. It also helps standardize records for public health or credentialing audits. Laboratory requisition form pairs with this to order the test and link the lot number to the result. Transfer of medical records form helps you send a finalized result to an employer, agency, or another clinic.

Must Ask TB Skin Test Results Questions

  1. What is the patient's full name and date of birth?

    Clear identifiers prevent mix-ups when multiple results are processed at once. This also speeds employer or school verification because the data matches their records.

  2. When and where was the PPD placed (date, time, and left or right forearm)?

    Placement details confirm the correct 4872 hour reading window and which arm to examine. They also document the procedure for legal and clinical accuracy.

  3. When was the test read, and what is the induration in millimeters?

    The millimeter measurement is the objective finding used to guide decisions; redness alone is not reliable. COVID-19 Test result reporting form shows a consistent way to record lab outcomes across programs.

  4. Based on risk factors, is the result interpreted as positive or negative?

    Interpretation depends on the mm threshold and the person's risk category, so capturing both avoids misclassification. This determines next steps such as x-ray, IGRA, or referral.

  5. Who verified the result (clinician name, title, signature, date, and facility contact)?

    Verifier details confirm authenticity for compliance reviews and deter altered or duplicate forms. They give recipients a direct contact if they need to validate the record.

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