Skin Testing Exempt Form

* = Required Information

Tuberculin Skin Testing Exemption

I (physician’s name) recommended that my patient .

Be exempt from tuberculin skin testing (TST) for the following reason:

I understand that U.S Centers for Disease Control and Prevention and the Iowa department of health consider TST to be valid and safe during pregnancy and recommend that pregnant women with risk factors (e.g., healthcareworkers) for exposure to tuberculosis (TB) should receive testing. I understand that not having TST screening may place my patient at risk for developing TB.

Physician Name

Date

Clinic Name

Clinic Phone Number

I (Employee) have read the above information and understand that tuberculin skin testing is generally considered safe in pregnant women. I understand that if I do not have a TB skin test, I may be risk for developing TB.

Name*

Date