SANGER UNIFIED SCHOOL DISTRICT

E 4212.4(a)
E 4312.4(a)
E 4112.4(a)
SANGER UNIFIED SCHOOL DISTRICT
1905 SEVENTH STREET • SANGER, CA 93657
(559) 875.6521/237-3171 FAX 875.0311
MARCUS P. JOHNSON, SUPERINTENDENT
EMPLOYEE PREVENTION CLINIC REFERRAL
Date
Name
Birthdate
Had a positive reaction to the T.B. skin test (
mm) and needs to have an X-ray.
X-rays are done at the:
Prevention Clinic/Fresno County Health Department 1221 Fulton Mall
Fresno, CA 93721
Telephone: 445-3409
The hours are: Monday thru Friday from 8:00 a.m. - 4:00 p.m. Call for an appointment. Medi-Cal accepted.
You must bring proof to the SUSD Human Resources that the X-ray has been taken.
School Nurse
Phone
CARTA DE REFERENCIA DE CLINICA DE PREVENCION PARA EMPLEADOS
Fecha
Nombre
Fecha de Nacimiento
Tubo una reaccion positiva de la prueba de piel para tuberculosis (
MM) y necesita ir a la
Clinica de Prevencion al Departamento de Salud del Condado de Fresno para un rayo-equis (X-ray).
Rayos-equis (X-ray) ala:
Clinica de Prevenci6n del Departamento de Salud del Condado de Fresno
1221 Fulton Mall
Fresno, CA 93721
EI numero de telefono es: 445-3409
Las horas son: Lunes hasta Viernes a las 8:00 de la manana a las 4:00 de la tarde. Favor de lIamar para una cita.
Aceptan Medi-Cal.
Usted necesita traer pruebas de los rayos-equis a la oficina de Recursos Humanos (Human Resources) del Distrito
Escolar Unificado de Sanger.
Si tiene algunas preguntas, favor de llamar a la escuela.
Enfermera de la Escuela
07-05
Telefono
E 4212.4(b)
E 4312.4(b)
E 4112.4(b)
SANGER UNIFIED SCHOOL DISTRICT
ANNUAL TB SCREENING AND PREVENTION PROGRAM
Name:
Date of Birth:
TB Skin Test Information Date given:
mm
Work Site:
Date Read:
Result:
X-Ray Information:
Date:
Result:
(place or clinic)
Medication given:
Yes
No
Began RX:
Completed RX:
(circle one)
Date
Date
The above information documents your Positive TB status with SUSD. To comply with the State of
California TB Communicability Standard, we need for you to answer:
Within the past SIX MONTHS have you experienced any of the following:
Excessive coughing/sputum Yes
Fevers Yes
No
Night Sweats Yes
Loss of weight Yes
Decreased appetite Yes
Chills Yes
No
No
Initials
No
No
No
Initials
Initials
Initials
Initials
Initials
A.) The above named individual was interviewed by SUSD Nursing Staff and denies any symptoms of
active TB Disease and considered Non-Infectious and Cleared for TB. A chest X-Ray is not medically
indicated at this time.
SUSD Nurse's Signature
Date
Tuberculosis Clearance: Many persons are requested to submit evidence of non-communicability with regards to tuberculosis. The
currently accepted practice in the State of California is as follows: Patients that are known to have a positive Mantoux PFD
(SkinTest) and a negative chest x-ray, with or without subsequent INH prophylaxis, in the absence of symptoms are not
re-examined periodically with x-rays as was once recommended (FCHD- Prevention Clinic 1221 Fulton Mall Fresno, CA 93721).
B.) The above named individual was interviewed by SUSD Nursing Staff and experiences one or more of
the above symptoms. It is advised that an X-Ray is needed to determine TB communicability status.
PMD/Prevention Clinic referral given:
SUSD Nurse's Signature
RETURN COMPLETED FORM TO HUMAN RESOURCES
07-05
Date