Symptoms Free Form – when NOT obtaining a Tuberculosis Skin Test – PPD

Student name: _______________________________________ Student ID ___________

Reason for NOT obtaining the Tuberculin PPD skin test:
1) History of Positive PPD skin test
o I have had a positive Tuberculosis test in the past. Date: _____________________
AND I have had a Negative Chest X-ray Date: _____________________
o I have _____ have not ______ received treatment for Tuberculosis, prescribed by:
__________________________________________________________________________________________

Completion Date: ____________

Copy of Negative X-ray report and treatment completion statement (if treatment received) from health care facility should be on file in the
Health & Wellness Office

Or 2) Physician requests student abstain from getting a Tuberculin PPD Skin Test at this time
o I have a doctor’s excuse to NOT obtain the Tuberculosis test at this time (attach physician’s note please). My
expected date to get the Tuberculosis test is ________________________.

If I abstain from getting the Tuberculin PPD skin test I acknowledge that I do not have any of the following
symptoms of active Tuberculosis and I understand that should I develop any of these symptoms I will immediately go
to the doctor for evaluation. I will also refrain from any clinical or class activity that may expose others to my
potential active case of Tuberculosis until the physician has cleared me.

ALL Answer Yes or No to the following conditions

YES NO
Night sweats
Loss of appetite
Cough that persists without explanation
Coughing up blood (hemoptysis)
Weight loss unexplained by diet or exercise
Recent exposure to active Tuberculosis patient
Change in my immune system (developed HIV, on corticosteroid or cancer
treatment or other drug or condition (transplant, etc) that may compromise my
immune system).
Fatigue, malaise unexplained by other health condition.

Signature date

Print name please Maryville student id. Number

Return to Online Nursing Team or fax to 314-529-6844 – Signature stating you continue to have no symptoms of active Tuberculosis is
required each year you are in clinical if you have a positive TB test.
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