Clearance #2

New Jersey Department of Health

Statement of Non-Infectiousness for

Individual with TB Disease

Student Name (Last, First, MI)

Birthdate (mm/dd/yyyy)

Street Address

Telephone Number

City

State

Zip Code

Name of School

Although the diagnosis of pulmonary or other infectious form of tuberculosis is suspected or has been confirmed in the individual identified above, I declare that the individual has been adherent with treatment recommendations by taking a minimum of 14 consecutive days of anti-tuberculosis treatment to date, is no longer experiencing TB-like symptoms and is negative for acid fast bacilli on smear. This individual poses no current risk to the public health, student population or school faculty and/or staff.
Name of Licensed Physician (Print)

Signature of Licensed Physician	Date

TB-10

AUG 12

TB-10, Statement of Non-Infectiousness for Individual with TB Disease

TB-10, TB, statement of non-infectiousness, TB Disease, school tb testing, tuberculosis

ewhite

2010-06-02

NJDOH