Student Instructions: 1. Complete sections, A, B and C 2. Give this form to the nurse on the day of the test
Address: _________________________________________________________________________________
Date read ____ / ____ / ____ Person reading _______________________ Data entered
Induration ________________ mm
BLOOD TEST (MSI) HBsAb, IgG for measles, mumps, rubella, varicella
SECTION B (Please Print) Please answer ‘yes’ or ‘no’ for all the questions below. All information is confidential.
Have you had or have had any illnesses which could affect your immune
system (leukaemia, lymphoma, HIV)?
SECTION C I have been informed about the Mantoux test in the on-line information supplied by the Infection Control
Officer and I have been given the opportunity to discuss the risks and benefits of the test (by email).
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