20 CAR pt. 104, Appendix A
1. Name
2. Date of Birth
3. Social Security Number, if applicable
4. Country of Birth
5. Gender
6. Race/ethnicity
7. Date of Arrival in the United States (Month /Day /Year)
8. History of TB Disease (Year, treatment)
9. BCG Status and Year Received
10. Past Tuberculin Status (Year tested, results)
11. Current Tuberculin Test Date and Reading
12. Brand of Tuberculin Antigen Used
13. Date, Place and Provider of Chest Radiograph (if indicated)
14. Chest Radiograph Result
15. HIV Status if Known