TB Skin Test Record Form

Testing Location: Seasons Magnolia 9550 FM 1488 Rd. Magnolia, TX 77354

Employee/Patient Name: *

Employee Name: *

TEST INFORMATION

Administered by: Tawny Sipe-Evans, RN

Date Administered: *

Injection Site: *

Manufacturer of PPD Solution: *

Expiration Date of PPD Solution: *

Lot #: *

RESULTS

Healthcare Professional: Tawny Sipe-Evans, RN

Date of Reading (must be read between 48 and 72 hours after placement): *

Induration (mm) *

Test Result: *

Negative

Positive

Adverse Reactions or Comments (If any):

Signature (Results read/reported by): *

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