New Jersey Department of Health

Tuberculosis Program

ANNUAL REPORT OF TB TESTING IN SCHOOLS

For the Calendar Year Ending December 31, (Year)

Instructions:	Numbers in the chart below are totals for newly tested individuals ONLY.

Please print or type.

No Testing Done

County

Public School Non-Public School

School Name and Address:

District

Category	Students Born in a High TB Incidence Country entering a US School for the First Time	Students Transferring Directly into a NJ School from a High TB Incidence Country	Employees (Teachers, Student Teachers, Others)	Volunteers and Contractors
TB Tests Completed
Significant Reactors/Positive IGRAs
Non-Reactors/Negative IGRAs
Significant Reactors/Positive IGRAs Given a Chest X-Ray
Normal Chest X-Rays
Abnormal X-Rays
Treatment for LTBI Prescribed
Treatment for LTBI Not Prescribed
LTBI Treatment Unknown
Diagnosed TB Cases

Completed By (Print)

Email Address

Telephone Number (Incl. Ext.)

( )	Ext.
Signature of Superintendent or Principal

Date

Distribution:	Original –	Retain On Site at School

TB-57	Copies –	School District Superintendent

OCT 14	Local Health Department / Local Health Officer

TB-57, Annual Report of TB Testing in Schools

TB-57, annual report, TB testing, TB Program, tuberculosis, testing, schools, communicable disease

EWhite

2006-08-15

NJDOH