Skip Navigation.

Site Map.

Help.

Account.

Cart.

Home

This Web site is a component of the SAMHSA Health Information Network.

Quick Find & Order

Top 50

Pubs in Series

Cost Recovery Items

Posters

Videos

Spanish

Drugs

Audiences

Issues

Publications Home

NCADI Home

This Web site is a component of the SAMHSA Health Information Network.

Assessment and Treatment Planning for Cocaine-Abusing Methadone-Maintained Patients
Treatment Improvement Protocol (TIP) Series10

Appendix D - TB/PPD Testing - Sample Forms

TB/PPD Testing

Patient Name_________________________ SS#__________ Unit: ... Sat ... AC ... SUPT
Section A (History)
Confirmed Negative TB test in past 30 days: ... Yes ... No Date (Mo/Day/Yr) _________ Location ______________ *If YES, DO NOT TEST; SKIP sections B and C; go to section D* Previous Positive test for tuberculosis: ... Yes ... No Date (Mo/Day/Yr) _________ Location ______________ *If YES (positive TB history), DO NOT TEST; go to section C - If NO, complete section B*
Section B (If Previously Negative)
Has patient ever had mumps? ... Yes ... No ... Unknown Is patient allergic to eggs?... Yes ... No Instructions: If patient is allergic to eggs, DO NOT USE MUMPS. Specify amount of erythema and induration in mm. First test for TB is positive if there is palpable induration of at least 5 mm. Test for mumps is positive if there is erythema of at least 5 mm. Test for Candida is positive if the erythema and induration are at least 5 mm. Repeat test for TB, if indicated, within 14 days. Second test for TB is positive if there is palpable induration at least 6 mm larger than was present from the first TB test. Results:... Positive ... Negative ... Anergic ... Equivocal ... No Show *If POSITIVE, complete section C*
Test	Placement	24 hr	48 hr	72 hr
TB-Initial
Mumps
Candida
Cocci
Date/Time
Initials
TB-Repeat
Date/Time
Initials
Section C (If Previously or Currently Positive)
Type:... Active ... Latent ... Unknown Referral: ... IDC ... Pulmonary Clinic... Hospital ... Private Physician ... None/Dropped Out ... Other__________________________ Treatment Status: ... Initiated/Continuing ... Discontinued ... Completed ... Not Initiated/Contraindicated ... Unknown If Treatment Discontinued or Not Initiated, reason: ... Previous Adequate Treatment ... Age ... Noncompliance ... Poor Liver Function ... Other Medical Problem __________
Treatment:	dose/frequency	start date	recommended end date	actual end date
... Aminosalicylic acid
... Ethambutol HCL
... Isoniazid & Pyridoxine(INH & B6)
... Rifampin
... Streptomycin
... Other
Section D
HIV Status: ... Positive ... Negative ... Unknown If POSITIVE, date of EARLIEST positive test (Mo/Yr) ______________ If NEGATIVE, date of MOST RECENT negative test (Mo/Yr) _____________

Substance Abuse Inpatient Unit

TB Testing Supplemental Questions
Chest X-ray results:	NAD / Consistent with TB / Equivocal
Followup (after discharge):
	None indicated
	Repeat Chest X-ray (suggested date)	____________
	Repeat skin testing (suggested date)	____________
	Infectious disease appointment (date)	____________
	Pulmonary appointment (date)	____________
	CDC report filed
	Unable to follow up: no known address / premature discharge
Important statistics:
	Residence: home / homeless / shelter / unknown
	Imprisonment: past / current
	IV drug abuse: past 6 months / remote history / never
	Three highest ranked drugs of use:
1. ____________	2. ____________	3. ____________
DSM III R Axis I	_______________
	_______________
	_______________
Axis II	_______________
_______________ Signature	_______________ Date

Substance Abuse Treatment Outpatient Clinic

PPD Testing Supplemental Questions
1. When was your last chest X-ray?		___________ Date
2. When were you last skin-tested for tuberculosis?		___________ Date
3. Were you tested with a single poke from a needle (PPD) or with four pokes from a small plastic applicator (tine test)?		___________ Date
4. Did you get tested with controls (anergy panel)?		___________ Y/N
5. Drug use in past 6-12 months (check if yes):
IV Heroin _____	Other opioids _____	Sedative/Hypnotic _____
IV Cocaine _____	Smoked Crack _____	Snorted Cocaine ______
IV Amphetamine ______	Other Amphetamine _____	PCP _____
Alcohol _____	Cigarettes _____	Marijuana _____
Hallucinogens _____
6. Residence in the past 6-12 months (check if yes)
Home _____	Homeless _____	Shelter _____	Unknown _____
ORDERS: Place the PPD skin test with two of the anergy panels on the same forearm with the PPD nearest the elbow and the Coccidioidin or Candida nearest the hand. DO NOT use mumps if allergic to eggs. Read and record the results at 24, 48 and 72 hours. DO NOT DO SKIN TESTING if the patient has ever tested positive for tuberculosis. DO NOT DO SKIN TESTING if the patient has ever been treated for tuberculosis. Repeat PPD test within 14 days if patient was anergic or had a skin reaction which would be interpreted as negative (less than 5 mm).
_______________ Date		____________________ Physician's Signature
____________________ (Signatures of all RNs/LVn involved in testing)		_______________ Date

Table of Contents

Initiatives | Funding | Home

	U.S. Department of Health and Human Services
	Substance Abuse and Mental Health Services Administration
	Center for Mental Health Services
	Center for Substance Abuse Prevention
	Center for Substance Abuse Treatment

(800) 729-6686

TDD: (800) 487-4889

Español: (877) 767-8432

SAMHSA Home | Freedom of Information Act | Department of Health and Human Services | The White House | USA.gov

Assessment and Treatment Planning for Cocaine-Abusing Methadone-Maintained Patients Treatment Improvement Protocol (TIP) Series10

Appendix D - TB/PPD Testing - Sample Forms

TB/PPD Testing

Substance Abuse Inpatient Unit

Substance Abuse Treatment Outpatient Clinic

Assessment and Treatment Planning for Cocaine-Abusing Methadone-Maintained Patients
Treatment Improvement Protocol (TIP) Series10