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,

    1. Interferon Gamma Release Assay(IGRA)
    2. Date obtained, Method, Result
    3. If TST or IGRA is positive, chest X-ray is REQUIRED to exclude active TB.
      1. Tuberculin Skin Test(TST)

      Date Given, Date Read, Result, Interpretation positive or negative.

  1. Please don't forget to have your physician's signature and other required information.