About this template
Managing tuberculosis (TB) screening documentation requires precision, speed, and strict organization. This TB Skin Test Results Google Form Template is designed for clinics, occupational health providers, and medical practices to record and verify Mantoux PPD skin test administrations and readings seamlessly. Instead of relying on fragmented paperwork or insecure spreadsheets, healthcare professionals can use this structured format to capture essential details including test manufacturer, lot numbers, administration site, exact induration measurements, and final result status.
Whether you are screening incoming healthcare personnel, university students, or patients requiring clearance for work or travel, this template streamlines data collection. It includes dedicated fields for reading dates, supervising physicians, and clinical follow-up indicators such as whether a chest X-ray is required. With Doc2Form, you can deploy this assessment instantly, centralize your screening records in Google Sheets, and maintain a reliable audit trail for compliance and employee health monitoring.
Key features
- Capture patient demographics and contact details accurately
- Record specific PPD brand, lot numbers, and expiration dates
- Document administration site, reading measurements, and interpretation
- Identify follow-up screening needs like chest X-rays instantly
- Securely store clinical records directly in connected Google Sheets
Use cases
- Onboarding new healthcare workers and clinical students
- Annual employee occupational health screenings
- Pre-placement clearances for volunteer organizations
- Community health outreach and mobile screening clinics
What this form collects
- Patient Full Name (Short answer)Enter your first and last name.
- Email Address (Short answer)We will use this to send a copy of your test results and clearance documentation.
- Company or Organization (Short answer)Enter the name of your employer, school, or institution requiring this test.
- Testing Location (Short answer)Specify the clinic, hospital, or facility where the test was administered.
- Date Administered (Date)Select the date the skin test was placed.
- Brand of TB (PPD) Test (Short answer)E.g., Tubersol, Aplisol.
- Lot Number (Short answer)Enter the manufacturer lot number of the PPD solution.
- Expiration Date (Date)Select the expiration date of the PPD solution.
- Site of TB Placement (Multiple choice)Indicate which arm and specific location the test was placed.
- Administered By (Short answer)Name and title of the healthcare professional who administered the test.
- Date Test Read (Date)Select the date the test results were evaluated.
- Induration (mm) (Short answer)Enter the measured size of the induration in millimeters (measure transverse to the long axis of the arm).
- Result Status (Multiple choice)Select the clinical interpretation of the induration measurement.
- Chest X-Ray Needed Status (Multiple choice)Indicate if a follow-up chest X-ray is required based on results and risk factors.
- Test Read By (Short answer)Name and professional designation of the clinician who read the test.
- Supervising Physician (Short answer)Name of the supervising MD or DO, if applicable.
- Healthcare Provider Signature / Verification (Paragraph)Please paste a link to your signed document (Google Drive, Dropbox, etc.) or type the verifying clinician's full name to confirm authorization.
- Date Signed (Date)Select the date of final verification.
FAQ
How do I start using this TB Skin Test Results template?
Click the template link to instantly copy it directly to your Google Drive via Doc2Form, where you can customize questions and settings to fit your clinic's workflow.
Can I track patient responses in real-time?
Yes, all submitted test results automatically populate a linked Google Sheet, allowing your nursing and administrative staff to review data instantly.
Is this form suitable for employee health screening programs?
Absolutely. It is specifically structured to capture employer details, test administrator credentials, and lot numbers required for workplace compliance records.
Can I add custom fields for our specific clinic requirements?
Yes, since the form lives in your Google Drive, you can easily add, edit, or remove questions using the standard Google Forms editor.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.