Instructor Application Form

							TST Instructor Agreement and Application Form

1. Be a RN who is knowledgeable in nursing principles and scientific methods (to give contact hrs).

2. Achieve a score of 80% on a written test on an overview of tuberculosis and skin testing.

3. Present the Tuberculosis Skin Test Course a minimum of two times a year.

4. Receive support for presenting the course, including the cost of class supplies, from employer and/or
sponsoring agency. If possible, open classes to other agencies and/or community groups.

5. Notify Mary Davidson (see below) at least one month in advance of course for supplies.

6. Submit sign in sheets and evaluations to Mary Davidson (see below) within 10 business days of your class.
      Mary Davidson
      Senior Program Specialist
      American Lung Assoc. of Midland States
      403 Seymour Ave.
      Lansing, MI 48933
      Email: mdavidson@alam.org
      Phone: (517) 484-7313
      Fax: (517) 484-2118

7. Understand that this Certification Program is a product of the Michigan Department of Community Health
and the American Lung Association of Midland States. The content cannot be altered.

I AGREE TO THE ABOVE CRITERIA AND WILL SUBMIT THE DOCUMENTATION.

Signature of Applicant________________________________________ Date___________

Print Name________________________________________________________________

Agency___________________________________________________________________

Work Address______________________________________________________________

City______________________________, Michigan Zip Code_______________________

Work Phone_____________________ Other Phone________________________________

Email Address_______________________________County of Work__________________

I agree to have my contact information listed on the www.michigantb.org website. ____YES____NO

I am a ____new instructor or a ____recertifying instructor.

Signature of Employer/Sponsor__________________________________Date___________
Please return this Form and Bio Data Form to Mary Davidson at ALAMS. Fax: 517-484-2118.


Updated 2009