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 examination.

If your skin test is positive, you will probably need an x-ray.

Please have your Physician complete the form below.

________________________________________________________________

NAME OF EMPLOYEE:

Mantoux (PPD) skin test performed:  (date) (results)

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

      (6) months.

Based on the above and my physical examination, I certify this person to be free to TB in its communicable form.

SIGNED: ____________________________________    DATE:_____________

                                               Degree

NOTE TO PHYSICIAN:  An x-ray may not be substituted for a Mantoux skin test.