Latent Tuberculosis Infection (Positive Skin Test) Reporting Form

* = Required

Health Care Provider Information

Patient Information

* Date of birth

Born in Canada?

Does the patient identify as Indigenous?

Reason for Testing

* What is the reason for testing for tuberculosis

Tuberculin Skin Testing Results

* Date administered

* Date read

(record in millimetres induration)

*A positive tuberculin skin testing is greater than or equal to 10 millimetres induration or meets the criteria outlined in the Canadian Tuberculosis Standards 8th Edition, Chapter 4, Table 1

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Interferon Gamma Release Assay Testing

Testing ordered?


Bacillus Calmette-Guérin Status

Received Bacillus Calmette-Guérin vaccine?

*Bacillus Calmette-Guérin vaccination should only be considered the likely cause of a positive tuberculin skin test if all the following apply:

  • Bacillus Calmette-Guérin vaccine was given after 12 months of age
  • There has been no known exposure to tuberculosis disease or other risk factors for tuberculosis infection
  • The person is either Canadian-born non-Indigenous or an immigrant / visitor from a low-tuberculosis-incidence country (less than 50 cases per 100,000 persons per year)

Read about international tuberculosis incidence rates. If there is uncertainty about the timing of Bacillus Calmette-Guérin vaccination, refer to the Bacillus Calmette-Guérin world atlas. Use an Interferon Gamma Release Assay if uncertainty still remains with Bacillus Calmette-Guérin vaccination and its timing.


Risk Factors


* Chest X-ray ordered  

* Chemoprophylaxis recommended  

* Patient declines chemoprophylaxis  

* Referred to respirologist  

* Health teaching completed (patient informed of signs and symptoms)?  

Personal Information and Privacy

Any personal information or personal health information submitted in writing will be collected, used and disclosed by members of Regional Council and Regional staff in accordance with the Municipal Freedom of Information and Protection of Privacy Act or the Personal Health Information Protection Act, where applicable.

Freedom of Information

Any information you share will be used only for the intended purpose for which it was provided. If you have any questions, email or call 905-980-6000 ext. 3779.

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