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Name
Have you ever had a TB skin test (TST)?
Have you ever had a POSITIVE TB skin test?
Have you ever had a BCG vaccine? (given in certain countries to prevent TB.)
Do you currently have any of the following symptoms?
***IF YOU DEVELOP ANY OF THE ABOVE, YOU MUST REPORT IT TO YOUR MANGER IMMEDIATELY***
I have read the information regarding T.B. skin testing and have had an opportunity to ask questions. I have supplied my current medical information.

TB Fact Sheet from the Centers for Disease Control: http://www.cdc.gov/tb/publications/factsheets/general/tb.pdf