CRANSTON PUBLIC SCHOOLS
CRANSTON, RI 02910
Dear Prospective Employee:
The Rules and Regulations of the State of
Rhode Island require that a Physician certify you are free of communicable
tuberculosis. This certification must be based on a skin test and physical
If your skin test is positive, you will
probably need an x-ray.
Please have your Physician complete the form
NAME OF EMPLOYEE:
Mantoux (PPD) skin test performed: (date)
If the Mantoux skin test was positive (>
10mm) I certify the above named employee has:
a history of adequate treatment for tuberculosis, specify:
is currently under my care for this infection and is not communicable, or
shows no indications of present disease on a chest x-ray taken in the past six
Based on the above and my physical
examination, I certify this person to be free to TB in its communicable form.
NOTE TO PHYSICIAN: An
x-ray may not be substituted for a Mantoux skin test.