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Tuberculosis Test Form

Full Name:
Date of Birth:
Email:
As a requirement for becoming an exempt provider for child care services through the Child, Family and Community Services, California Child Care Alternative Payment Program, the Department of Education requires a current tuberculosis clearance for the agency records.
Date you received a test for tuberculosis, also called a P.P.D:
Please return to the place where you had the test done in order to get a reading.
Please specify the date and time your reading will be done. If you fail to return on the date above, the reading will not be validated and the P.P.D. will have to be repeated.
Date of Reading:
Time:

Results

P.P.D. Reaction (mm):
Date of Reaction:
Place Where Chest X-Ray Was Done:
Date of Chest X-Ray:
Chest X-Ray Results:
Date of Treatment for Active Tuberculosis:
Months of Preventative Treatment for Tuberculosis Infection:
Date Preventative Treatment Was Completed:
Date Cleared of Tuberculosis Contagious State:
Date:
By checking this box I am certifying that the above information is true and accurate: