About this template
The TB Test Results Entry Form is designed for healthcare providers, employee health clinics, and occupational health nurses who need a systematic way to record and track tuberculosis (TB) screening results. Managing routine screenings or multi-step PPD skin tests requires precision, organization, and a reliable method for capturing clinical data without missing key details like lot numbers, expiration dates, induration measurements, and reading dates.
Using Doc2Form, you can instantly convert this template into a fully functioning Google Form to streamline clinical documentation. The form captures critical patient information, test administration details, read results, and follow-up requirements such as chest X-rays. By maintaining a centralized digital log, healthcare teams reduce the risk of transcription errors, keep patient records audit-ready, and ensure seamless tracking across both initial placement and secondary follow-up readings.
Key features
- Track multi-step PPD skin tests and read dates accurately.
- Record vital clinical details including lot numbers and induration measurements.
- Determine immediate requirements for follow-up chest X-rays.
- Maintain centralized, organized digital records for patient compliance.
- Access and submit screening data securely from any mobile or desktop device.
Use cases
- Annual employee health screenings for healthcare and childcare staff.
- New hire medical onboarding and tuberculosis clearance.
- Community health clinic tuberculosis surveillance programs.
- Student clinical placement health clearance tracking.
What this form collects
- Patient Full Name (Short answer)Enter the patient's first and last name as it appears on official records.
- Email Address (Short answer)Enter the patient's or employee's primary email address for follow-up communication.
- Company / Organization (Short answer)Select or enter the organization associated with this screening.
- Test Step (Multiple choice)Indicate whether this is for the initial placement/test or a secondary follow-up step.
- PPD Test Brand (Dropdown)Select the manufacturer or brand of the tuberculin PPD solution used.
- TB Placement Site (Multiple choice)Specify the anatomical site where the injection was administered.
- Date Administered (Date)Select the date the PPD test was administered.
- Lot Number (Short answer)Enter the lot number of the PPD serum.
- Expiration Date (Date)Select the expiration date of the PPD serum.
- Administered By (Short answer)Enter the name and credential of the clinician who administered the test.
- Supervising Physician (Short answer)Enter the name of the supervising physician, if applicable.
- Date Test Read (Date)Select the date the test result was read (typically 48–72 hours post-administration).
- Induration (mm) (Short answer)Enter the measured size of induration in millimeters (enter 0 if none).
- TB Test Result Status (Multiple choice)Indicate whether the reading result is positive, negative, or borderline.
- Test Read By (Short answer)Enter the name and credential of the healthcare professional who read the test.
- Chest X-Ray Needed Status (Multiple choice)Indicate if a follow-up chest X-ray is required based on the test outcome.
FAQ
How does Doc2Form help me use this template?
Doc2Form instantly converts this template structure into a ready-to-use Google Form in your Google Drive, allowing you to start collecting test results immediately.
Can I customize the questions to match our clinic's specific testing protocol?
Yes. Once the template is in Google Forms, you can fully edit, add, or remove any fields to suit your exact clinical requirements.
Is patient data secure when using Google Forms?
Google Forms operates within your organization's Google Workspace environment, which adheres to robust enterprise security standards.
Can nurses and clinic staff access this form on mobile devices?
Yes, Google Forms are fully responsive and work seamlessly on tablets, smartphones, and desktop computers for convenient data entry on the go.
How can I review and analyze the submitted test results?
All submissions are automatically organized into a linked Google Sheets spreadsheet, making it easy to filter records, track follow-ups, and generate reports.
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.