Clearance #1

New Jersey Department of Health

Statement of Non-Infectiousness for Symptomatic Individual

Student Name (Last, First, MI)

Birthdate (mm/dd/yyyy)

Street Address

Telephone Number

City

State

Zip Code

Name of School

Although the presence of TB-like symptoms was confirmed on assessment, a chest radiograph and appropriate subsequent testing has ruled out the presence of communicable tuberculosis. I declare that the individual above has been fully evaluated and determined to be free of communicable tuberculosis disease. This individual poses no current risk to the public health, student population or school faculty and/or staff.
Name of Licensed Physician (Print)

Signature of Licensed Physician	Date

TB-9

AUG 12

TB-9, Statement of Non-Infectiousness for Symptomatic Individual

TB-9, statement of non-infectiousness, symtomatic individual, tuberculosis, TB, TB Services, school TB testing

ewhite

2010-06-02

NJDOH