Printable TB Skin Test Form for Medical Screening and Documentation

Use a standardized Mantoux screening record that captures patient data, injection details, and induration measurement in millimeters to meet employment, school, or clinical compliance rules.

Required Fields for Accurate Documentation

Each record sheet should contain clearly separated sections to avoid omissions during administration and reading.

• Patient identification: full legal name, date of birth, ID number, contact details
• Medical background: prior tuberculosis exposure, BCG vaccination history, immune status
• Administration details: date, exact time, dose (0.1 mL PPD), intradermal site on forearm
• Provider data: name, license number, signature
• Reading section: evaluation performed 48–72 hours after placement
• Result entry: induration size recorded in mm, risk category, interpretation (negative or positive)

Measurement Standards

Measure only the raised, hardened area across the forearm using a millimeter ruler. Do not document redness. Record “0 mm” if no induration is present. A 5 mm threshold applies to high-risk groups such as immunocompromised patients, 10 mm for healthcare personnel and recent immigrants, and 15 mm for individuals with no known risk factors.

How to Prepare and Submit the Record Sheet

The document should be formatted for clear black-and-white output on US Letter or A4 paper. Avoid compressed layouts that reduce legibility after scanning.

1. Download a fillable PDF or create a structured template with labeled sections
2. Print a clean copy without background graphics
3. Complete entries in permanent ink or secure digital fields
4. Verify dates fall within the 48–72 hour reading window
5. Attach clinic stamp if required by employer or academic institution

Common Compliance Errors

Submissions are rejected due to missing millimeter measurements, absent provider credentials, unreadable handwriting, or reading performed outside the accepted time frame. Review every field before submission to prevent repeat appointments.

When an Alternative Is Accepted

Some organizations allow an interferon-gamma release assay laboratory report instead of the Mantoux method. Confirm policy rules before scheduling, especially for healthcare onboarding.

Printable TB Skin Test Form

Download a clear tuberculosis screening record template that includes patient identification, antigen placement details, and induration measurement fields measured in millimeters to meet employer and school clearance requirements.

The document should contain labeled sections for full legal name, date of birth, government ID number, prior BCG vaccination status, and risk category. Administration details must specify 0.1 mL of purified protein derivative delivered intradermally on the forearm, with exact date and time recorded. The evaluation section must confirm reading at 48–72 hours after placement and include the transverse diameter of induration in mm, not redness. A signature line with provider name, license number, and clinic stamp prevents rejection during onboarding or academic enrollment.

Use standard US Letter or A4 layout with high-contrast black text, avoid background graphics, verify all dates before submission, and keep a scanned copy for personal medical records.