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TST REFERRAL Date MSDR Name Birthdate Address Directions Parent's Names

TST REFERRAL Date MSDR Name Birthdate Address Directions Parent's Names Date TST Given Results (in mm) TST Given By TST Read By School Name ___ School District Contact Person Refer to your local health department if TST results are 5 mm or greater of induration.

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TST REFERRAL Date MSDR Name Birthdate Address Directions Parent's Names

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  1. TST REFERRAL DateMSDR NameBirthdate Address Directions Parent's Names Date TST GivenResults (in mm) TST Given ByTST Read By School Name___School District Contact Person Refer to your local health department if TST results are 5 mm or greater of induration. Please bring this referral sheet. Child must be accompanied by a parent. ************************************************************************************************ TST REFERRAL FechaMSDR NombreFecha de Nacimiento Domicilio Instrucciónes para encontrar el domicilio Nombre de padres Fecha de TSTResultados (en mm) TST dado porTST leidopor Nombre de la escuela ______Distrito Escolar ____________ Dirección de la escuela Persona de contacto Favor de reportar a sudepartamento local de saludsi los resultados de TST indican 5 mm o mas de induración. Favor de traeresta forma. El padre debe de estar con el niño.

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