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CLINIPATH PATHOLOGY FSE-025

Consent to Mantoux and Blood Testing (UWA)

Version: 1.0.A 05-Mar-2008


UNCONTROLLED IN PRINTED FORM

Student Instructions: 1. Complete sections, A, B and C 2. Give this form to the nurse on the day of the test

SECTION A (Please Print)

Family Name: First Name: _______________________

Date of birth:__________________ M † F † Phone No: _____________ Mobile:______________

Address: _________________________________________________________________________________

_________________________________ Email: ______________________________________________

Student no.________________________ Course: ______________________________________________

OFFICE USE ONLY:


MANTOUX TEST (MAN)
Date of administration ____ / ____ / ____ Dose _______________ IU Payment received

Type (circle) Human Avian Expiry date __________________

Batch number: __________________

Person administering __________________

Date read ____ / ____ / ____ Person reading _______________________ Data entered

Induration ________________ mm

BLOOD TEST (MSI) HBsAb, IgG for measles, mumps, rubella, varicella

Date of collection ____ / ____ / ____ Person collecting ___________________________

SECTION B (Please Print) Please answer ‘yes’ or ‘no’ for all the questions below. All information is confidential.

Questions No Yes If ‘yes’, briefly describe


Have you had a previous Mantoux test (tuberculin test)?
Have you ever had treatment for tuberculosis?
Has anyone close to you had tuberculosis?
Have you been vaccinated against tuberculosis (BCG)?
Have you had an MMR vaccination within the last 4 weeks? Mantoux is
Have you had a viral illness in the last 4 weeks? contraindicated
Are you taking any medication or having any treatment which could affect
your immune system (corticosteroids, chemotherapy, radiotherapy)?

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).

Signature: _________________________________ Date: _____________________

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