TB CLEARANCE LETTER

[Practice or occupational health clinic name]
[Address]
[Phone and email]

Date: [Date you write the letter]
To: [Employer, school, program, or To whom it may concern]

Re: [Patient's full name]
Date of birth: [Date]
Role or program: [Job title, placement, or volunteer role, if the requester gave one]

[Patient name] asked me for this letter and agreed to what it shares.

TB HISTORY
Prior positive TB test or TB disease: [None, or the year, the test, and any treatment, with records if available]
BCG vaccine: [Not received, received, or unknown]

TB TEST
Test: [TB blood test, naming the IGRA, or tuberculin skin test, one-step or two-step]
Date: [Date the blood was drawn, or the dates the skin test was placed and read]
Result: [Negative, positive, or indeterminate; for a skin test, the induration in mm]

CHEST X-RAY
[Not needed: negative test and no symptoms; or the date of the X-ray and the result, e.g. no evidence of active TB]
Other tests: [Sputum tests and their results, if symptoms or the X-ray called for them, or none]

SYMPTOM SCREEN
Date: [Date]
Result: [No prolonged cough, coughing up blood, fever, night sweats, weight loss, or unusual tiredness; or what was found and how it was assessed]

CONCLUSION
[No evidence of active TB disease, or TB infection without active disease and not contagious, in the requester's terms]
From a TB standpoint, [patient name] can [start work, attend school, or begin the placement].

TREATMENT FOR TB INFECTION
[Not applicable; or offered on date, and started, completed, or declined. Include only if the patient agrees]

NEXT SCREENING
[Not needed unless there is an exposure or new symptoms, or what the employer's policy or local rules require]

[Your name, credentials]
[License or registration number]
[Signature]

To verify this letter: [Practice phone or email]