Printed Name                                                    

was administered the following:

PPD Test_______                   Date________             Site__________          Results______

PPD Test__________             Date________             Site__________          Results______

Chest X-ray________               Date________             Site__________          Results______

Signature, written name, and Title of Person Administering Test

Signature, written name, and Title of Person Reading Results

Location of Test Administration (name of Doctor’s office, clinic, Health Dept. etc.)

*Proof of PPD TB Skin test or chest x-ray must be dated within the last 12 months.  The 2 step PPD TB test requires at least 2 weeks.  Please plan ahead so that you have the results prior to the first day of class.  This is a REQUIREMENT for the program and to train/work in the HealthCare Field.