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TB test renewal
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Faculty of Medicine, University of Toronto PHYSICIAN ASSISTANT PROFESSIONAL DEGREE
PROGRAM IMMUNIZATION RECORD
TB TEST renewal
SUBMISSION OF THIS FORM IS MANDATORY IF THE RESULTS OF LAST YEAR’S TB TEST WAS NEGATIVE.
(If your TB test result from the last year was Positive, further testing is not required.) Name of Student: __________________________________________ Student #: ___________________ Academic Session: 20__ Year of Study: __ DATE OF TUBERCULIN TEST: _______________________________ Results: Negative Positive * Reading (induration) in mm.__________ Date of last known negative: ___________________ Previous BCG Vaccination: No Yes BCG_________________ Date of Previous treatment for TB: No Yes *If test results are positive a chest x-ray will be required- To be determined by the BScPA Program, Faculty of Medicine, University of Toronto. CHEST X-RAY: X-Ray Date: ______________________________ Results: ________________ (normal or abnormal)
Please return to: BScPA Program Office, 263 McCaul St, 3rd Floor, Toronto, ON, M5W 1T7, [email protected], Fax. 416-946-3511
Clinic/Health Centre Authorization: ______________________________________________________________________________________________ (name, address and phone number of centre where form completed) Signature: _________________________________(trainee cannot sign own form) Date: ___________________
Student Authorization: I give my consent that the information on this form may be shared with university/hospital teaching and administrative staff in appropriate cases. Signature of Student: __________________________________________ Date: _________________
