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    Documentation of Pulmonary Tuberculosis Status

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    You will be asked for the following information on the
    Documentation of Pulmonary Tuberculosis Status Form

    • Applicant’s Name
    People infected with HIV, and people living in group residential facilities are considered to be at high risk for pulmonary tuberculosis. In order to protect patients and staff, the following documentation is required:

    • If Patient is HIV Negative:
      • PPD (within 3 months) Date and result: Negative or Positive
      • If PPD positive: CXR (Within 3 months) Date and result: Negative or Positive For Pulmonary TB
    • If Patient is HIV Positive:
      • CXR (Within 3 months) Date and result: Negative or Positive For Pulmonary TB
    In either case, if patient has active pulmonary TB, patient must have received continuous treatment for at least 2 weeks and show 3 consecutive negative AFB smears prior to admission.
    • Date treatment started

    • Date of negative AFB’s (can list more than one)

    Attending Physician Information:
    • Physician's name

    • Signature

    • Physician CA License

    • Date

    • Address

    • Phone

    • Pager

    • Fax