Alaska Tuberculosis Program Manual - Epidemiology - State of Alaska

ALASKA DEPARTMENT OF HEALTH AND SOCIAL SERVICES
Division of Public Health
Tuberculosis Program
SCHOOL TUBERCULIN TESTING REPORT
Please mail or fax report to: School:
State of Alaska TB Program
3601 C Street, Ste. 540 DEADLINE: December 15th Address:
Anchorage, AK 99503
Phone: 907-269-8000 City/State/Zip:
Fax: 907-562-7802 (If name/address is incorrect, please make corrections above)
Please check the appropriate box:
Public School Telephone:
Private School
Principal’s/Director’s Name:
District: Reported by:______________________ Date:_______
GRADE LEVEL
KINDERGARTEN*
FIRST GRADE*
SECOND GRADE*
THIRD GRADE*
FOURTH GRADE*
FIFTH GRADE*
SIXTH GRADE*
SEVENTH GRADE*
EIGHTH GRADE*
NINTH GRADE*
TENTH GRADE*
ELEVENTH GRADE*
TWELFTH GRADE*
*Grades in which PPD testing is required.
TB-001-A
A B C D E F G
NUMBER OF:
CONTINUING STUDENTS NEW STUDENTS
NEGATIVE PPD
TEST
STUDENTS IN COMPLIANCE
NEWLY
POSITIVE PPD
PREVIOUSLY
POSITIVE PPD
MEDICAL
EXEMPTION
STUDENTS
NONCOMPLIANT
FOR OFFICE
USE ONLY