Please ask your physician to complete this page 3.
- Your name
- Check your answers in page 2 by your physician. Yes or No
- If no, skip to page 4 if necessary.
- If yes, please complete the following TB screening examination.
Does the student have a history of BCG vaccination? Yes or No -->No,
- Interferon Gamma Release Assay(IGRA)
- Date obtained, Method, Result
- If TST or IGRA is positive, chest X-ray is REQUIRED to exclude active TB.
- Tuberculin Skin Test(TST)
Date Given, Date Read, Result, Interpretation positive or negative.
- Please don't forget to have your physician's signature and other required information.