Student’s Name: _______________________________________________________________________
Cardinal Stritch University
TB SKIN TESTING
INFORMATION AND CONSENT
Tuberculosis is an infectious disease that is carried through the air in tiny particles that are produced when people with TB cough, sneeze, speak or sing. It usually affects the lungs, but also can affect the heart, kidneys, bones and other organs of the body.
The Mantoux skin test is the recommended method of identifying tuberculosis infection. You cannot get TB from a skin test.
Side effects are rare. A very sensitive person may develop redness or a blister at site of injection. Strongly positive reactions may include an ulcer or scarring at the test site.

CONTRAINDICATION:
1.

2.

The Mantoux skin test should not be given to persons who had a previous positive skin test reaction or to persons who have had an active case of tuberculosis.
Pregnancy is not a contraindication to TB testing. However, pregnant women must present an order from their personal care provider before Student Health Services can provide the test.

TB SKIN TEST MUST BE READ 48–72 HOURS AFTER THE INJECTION!
FAILURE TO HAVE THE TEST READ WILL RESULT IN HAVING TO HAVE IT REPEATED!
Yes
Have you been vaccinated with MMR, Varicella, or
Influenza vaccine in the past 4 weeks?
Have you had a TB Skin Test before?
- If yes, when/where ____________________
- Type/Results ___________________
Have you been treated for TB?
Do you have any symptoms of TB such as unexplained productive cough, fevers, night sweats, weight loss, bloody sputum?
Have you been exposed to TB? (if yes, document who, when, where, etc.)

No

Yes

No

Do you suspect or know that you HIV infection?
Any history or medical conditions that increase the risk of TB (e.g. silicosis, gastrectomy, poorly controlled diabetes mellitus, leukemia, lymphoma, other malignancies, end-stage renal disease, and body weight 10% below ideal)?
Current use of oral or injected corticosteroid or immuno-suppressants? Born or lived in Asia,