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Indications for use Complete this form for any client receiving or requesting a tuberculin skin test such as contacts persons targeted for screening or walk Tuberculin Skin Test (Mantoux only; no tine tests). Must be completed within 12 months prior to the start of classes. Date given: ___/___/___.

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TUBERCULOSIS SKIN TEST FORM Healthcare Professional Patient Name PPD Mantoux Test Result Negative Positive Signature results read reported Playstation 4 Disk Cheaper Than Retail Price Buy Clothing Accessories Ps4 Disc Slot

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