Example file

The signed TB certificate and its supporting result

Illustrative example. Caregiver and physician names, licence and NPI numbers are hidden. The dates and the NEGATIVE result shown belong to this sample — a real file carries that caregiver’s own examination date and result.

This example runs to two pages because it includes a laboratory result; what the file contains reflects the evidence the physician reviewed.

A signed certificate records a physician’s examination decision; it is not a determination by any state agency.