New Jersey Department of Health

Tuberculosis Program

TUBERCULOSIS (TB) TESTING SURVEY RESULTS

Name of Agency

County

Date(s) of Testing

Street Address

Category Tested

Employees

Clients

Other (Specify):

____________________	Type of Program

Initial

Annual

Other (Specify):

____________________
City, State, Zip Code

Group Tested

Type of Test Used

Total Tested

Age Group	TB Testing Results	X-Ray Results	Number of

Positive Reactors Prescribed INH
Number Tested

and Read	Number of

Positive Reactors *	Compatible

with TB	Not Compatible

with TB	Not Done
Under 5 Years
5 - 14 Years
15 - 34 Years
35 - 44 Years
45 - 64 Years
65 and Over
Not Stated
TOTAL
*	a.	A reaction of 5 mm or more of induration is classified as positive in the following groups:

(1)	Persons who have close contact with TB.

(2)	Persons who have previously had TB disease.

(3)	Persons with organ transplants and other immunosuppressed persons (including persons taking a prolonged course of oral or IV corticosteroids or TNF antagonists).

(4)	Persons with fibrotic changes on chest x-ray.	b.	A reaction of 10 mm or more of induration is classified as positive in the following groups:

(1)	Persons who inject illegal drugs.

(2)	All others.
Prepared By

Telephone Number

TB-43

SEP 13	Page 1 of 2 Pages.

REPORT OF TUBERCULOSIS REACTORS

Name and Address of Reactor	Date of

Birth	TB Test Results	X‑Ray Results	Preventive Therapy INH Prescribed
Date	Induration in mm	Date	Compatible

Not Done	Not Compatible With TB	Not Done	Yes	No

Mail Report to: New Jersey Department of Health

Tuberculosis Program

TB-43	PO Box 363

SEP 13	Trenton, NJ 08625-0363	Page 2 of 2 Pages.

New Jersey Department of Health and Senior Services

Elaine White

2013-09-24

ewhite

NJDHSS