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Get Printable Tb Questionnaire

D within 6 months prior to start of classes for recent or prior positive TST or IGRA Date Obtained: / / M D Result: Normal / Abnormal Y 5. Provide or attach information regarding past or present treatment for latent or active TB infection: 6. Health Care Provider Contact Information sign only when testing completed Provider Name: Address: Provider Signature City State Zip Code Country Phone Number: Fax Number:.

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