UNIVERSITY OF CALIFORNIA, SAN DIEGO

TUBERCULOSIS SCREENING ADMISSION

REQUIREMENT
Dear Student,
The health of the individual can affect the health of the campus community. UCSD is committed to protecting
the health and well-being of all our students. In order to protect the campus from communicable diseases,
screenings are part of the admission process for all new and re-admitted students prior to arrival to UCSD.
Your answers to the Tuberculosis (TB) screening questions indicate you are at higher risk for tuberculosis and
are REQUIRED TO HAVE TESTING FOR TB.
Please read and follow the instructions below:
1. Read this entire instruction page.
2. Print the assessment form.
3. Visit your health care provider to complete the form and perform all required testing. Please also
take your Immunization Requirements form to ensure you gather all required information.
4. Tuberculosis Testing must have been performed within 1 year of entering the University.
5. Forms are submitted to The University of California, San Diego, Student Health Services via
mail, fax or e-mail.
Mail

E-mail

University of California, San Diego

Student Health Services
9500 Gilman Drive #0039
La Jolla, CA 92093-0039

Fax

1-858-534-7545

shstb@ucsd.edu
*E-mail is not a secure method of sharing medical information. If you are unable to send the form by mail or fax,
e-mail submissions will be accepted. If you e-mail your form, you acknowledge that there are risks of sending
medical information via the internet. E-mails sent to this e-mail address will not receive a response.

CONFIRMATION OF RECEIPT OF YOUR DOCUMENT(S) IS NOT POSSIBLE.

Clearance can take 5-7 days after receipt
Check the following UCSD web information to verify TB compliance status:
Undergradates check your TB status on MyApplication
Graduates check your TB status on GradApply
If the status has not changed, please check your UCSD email for a secure message from
Student Health, as there may be a problem with your form.
For questions or concerns not answered by the above information, contact us via the Student Health
website at https://shs.ucsd.edu/home.aspx Online Services section - Ask a Nurse TB Question.

HED:pg TB assessment_Mar2016

TUBERCULOSIS (TB) ASSESSMENT FORM

_________________________
Name

UC SAN DIEGO

_______________________
Date of Birth

_____________________
Student ID

THIS STUDENT IS REQUIRED TO COMPLETE TUBERCULOSIS TESTING PRIOR TO ENROLLING IN CLASSES.

The form must be completed and signed by a LICENSED HEALTH CARE PROVIDER and must be received by
UCSD Student Health via mail, fax or e-mail, noted at the bottom of the page, NO LATER than July 15, 2016.
TESTING MUST BE DONE BETWEEN SEPTEMBER 2015 TO PRESENT DATE

TUBERCULIN SKIN TEST (TST) If no history of BCG

TB BLOOD TEST (Recommended if history of BCG)

5 mm is positive if:

QUANTIFERON - Interferon Gamma Release Assay IGRA

Recent close contact with someone with active infectious TB

disease
Immunosuppressed (spleenectomy, HIV, chemotherapy,
transplant patient)
History of an abnormal chest x-ray suggestive of TB

If not available, may do a Tuberculin Skin Test (TST) or Chest

X-ray.

otherwise 10mm is positive

Date Obtained:________________

Date placed:
Date read:
Result:_______ mm induration.
(If no induration, write )
Interpretation: Negative
Positive

Result: Negative Positive

(IF POSITIVE, PROCEED TO CHEST X-RAY)
Indeterminate
(If Indeterminate, repeat test or proceed to Chest X-ray)

(IF POSITIVE, PROCEED TO CHEST X-RAY)

CHEST X-RAY (REQUIRED if TST or Quantiferon/IGRA is positive)
Date of Chest X-ray:___________
Result: Normal Abnormal
MUST ATTACH WRITTEN RADIOLOGY CHEST XRAY REPORT (DO NOT SEND FILM/CD)
Any abnormal result, including scars and old granulomatous changes MUST PERFORM SPUTUM TESTING
TB SPUTUM
Results (AFB smear and cultures x3 are REQUIRED if the Chest x-ray is read as abnormal)
1. Date:__________AFB:__________Culture:__________
2. Date:__________AFB:__________Culture:__________
3. Date:__________AFB:__________Culture:__________

Licensed Health Care Provider Name

Mail, Fax or E-mail form to:

Fax: 1-858-534-7545
E-mail: shstb@ucsd.edu
HED:pg TB assessment_Mar2016

Signature

University of California San Diego

Student Health Services
9500 Gilman Drive #0039
La Jolla, CA. 92093-0039

Date
For questions contact us:
https://shs.ucsd.edu/home.aspx
Online Services
Ask a Nurse TB Question