Healthcare TB English Consent Form

HEALTHCARE TB ENGLISH CONSENT FORM

Purpose

This form documents the patient's informed consent for tuberculosis (TB) screening, which may include a Tuberculin Skin Test (Mantoux), an Interferon-Gamma Release Assay (IGRA) blood test, or both, as indicated by the healthcare provider. The test is intended to detect latent or active Mycobacterium tuberculosis infection. The patient should read the information below, ask any questions, and sign to indicate voluntary consent.

Patient Information

Insurance / Billing

Medical History — Relevant to TB

Please indicate if any of the following apply:

Prior diagnosis of active TB

Previous treatment for TB

Known exposure to someone with active TB

History of BCG vaccination

Prior TB test performed  Date of prior test:

Proposed Test / Procedure

Select the TB screening modality to be performed (check all that apply):

Tuberculin Skin Test (Mantoux) — injection of purified protein derivative (PPD) intradermally; requires return visit for reading 48–72 hours after administration.

Interferon-Gamma Release Assay (IGRA) — blood test requiring a blood draw; single visit for sample collection.

Risks, Benefits and Alternatives

I understand the benefits of TB screening include identification of latent or active infection so that appropriate treatment, monitoring, or public health measures may be provided. I understand there is no guarantee of detection. I understand the risks may include pain at the injection site, redness, swelling, bleeding, local infection, fainting, allergic reaction, or inaccurate results (false positive or false negative). For IGRA, risks associated with blood draw may include bruising, bleeding, infection, or fainting.

Alternatives to testing include decline of testing at this time. I understand that declining testing may have implications for my employment, clinical care, or public health obligations in certain circumstances.

By checking the box below I acknowledge that the risks, benefits, and alternatives have been explained to me and I had the opportunity to ask questions.

I acknowledge explanation of risks, benefits, and alternatives and my questions have been answered to my satisfaction.

Confidentiality and Reporting

I understand that tuberculosis is a reportable condition to public health authorities. By signing this form I authorize the release of test results and relevant clinical information to public health authorities as required by law. Results may also be released to my employer or other authorized entities when necessary for public health, infection control, or workplace health requirements as permitted by law.

I acknowledge receipt of the facility's privacy notice and understand how my health information will be used and disclosed in connection with TB testing.

I acknowledge the privacy and reporting statement above.

Authorization and Consent

I authorize the healthcare provider and qualified staff to perform the selected TB screening test(s), to obtain blood specimens if applicable, to administer and read a Tuberculin Skin Test, and to record and disclose results to public health authorities and other authorized persons as described above. I understand that if a skin test is selected I must return for the reading appointment; failure to return may result in an unread test and the need for repeat testing.

Procedure Details (to be completed by staff)

For Tuberculin Skin Test administration:

For Tuberculin Skin Test reading (48–72 hours after administration):

For IGRA / Blood Test:

Patient Consent and Certification

By signing below I certify that I am the patient or authorized to sign on behalf of the patient, that I have read or had read to me the information on this form, that the procedure(s), risks, benefits and alternatives have been explained, and that I consent to the performance of the selected TB screening test(s). I understand that I may withdraw consent at any time prior to test administration by notifying clinical staff. I authorize release of the results as described above.

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