CHICAGO PUBLIC SCHOOLS

Occupational Medicine Testing Facilities

In accordance with our policies and in an effort to process you in a timely manner please do not present with
unattended children under the age of 12 as the treating facility will be unable to complete your employment testing.
We do not schedule appointments for these services as we are a walk-in facility and patients are taken in the order that
they sign in. In an effort to cut down on phone calls during peak hiring season we ask that you do not call the clinic to
schedule an appointment as an appointment will not be given.
As part of your on-boarding process you are to submit to a drug screening within seven (7) days of receipt of your
offer of employment and prior to visiting the CPS Employee Staffing Center.

Patient Name: _____________________________________ S. S. #: _______ - _____ - _______

Employer: Chicago Public Schools (CPSPHY) Date of Birth : _________________

Please present with this completed form along with the required CPS
Tuberculosis Form that was attached in your on-boarding email.

Patient is the Responsible for Payment: Cash (please bring the exact amount) and credit cards are currently
accepted. No personal checks will be accepted.
10-Panel Non-Nida Urine Drug Screening $30.00 (Valid picture I.D. Required)
Tuberculosis Test & Reading $20.00 (Skin Test)
Quantiferon Gold TB Blood Test $70.00
Past Positive Questionnaire, Chest X-ray & Reading $108.00

Tuberculosis Testing: Please note that you can choose to have your Tuberculosis Testing done at your Primary
Care Physician or other medical facility of your choice. However, for your convenience Tuberculosis Testing is
also available at the facilities listed below.
Once you have the test placed you will be required to return to the clinic to have the skin test read by 48 to no later than 72
hours from initial placement of your skin test. If you fail to present to the clinic within the required time frame to have the
test read you will be required to have a second Tuberculosis Test placed (7 days from your initial test) at your expense and
risk a delay in your employment. Also be sure to communicate to your medical care provider if you have ever had a history
of a positive skin test in the past as will be required to either have chest x-ray or a quantiferon blood draw.
Keep in mind that most locations listed below are not open on the weekend and therefore will not be able to do a
Tuberculosis test on a Thursday as we are not available on the weekend to read them.
Authorization Instructions: Since the patient is responsible for payment in full at their time of service an authorized by
signature from CPS is not required. The candidate will need to sign a consent/release of information form in order for
MercyWorks to provide service and report the results of these tests directly to the CPS designated confidential contact.

MercyWorks on Pulaski Near

5525 South Pulaski, Suite 2-200 Midway
Chicago, Illinois 60629 Airport
(773) 284-5278, Fax (773) 585-0395
(M-F 8:00am 4:30pm)

MercyWorks at Dearborn Station

47 West Polk Street, Suite G1 Near South
Chicago, Illinois 60605 Loop
(312) 922-3011, #4 Fax (312) 583-1712 Printers Row
(M-F 8:00am 4:30pm)

Revised 6/2017 Page 1 of 2

 CHICAGO PUBLIC SCHOOLS
EMPLOYEE TB TEST FORM

Illinois School Code requires Chicago Public Schools to screen employment candidates for TB. As a
condition for employment in the Chicago Public Schools (CPS) you must be free of tuberculosis (TB). In
addition, your physician must provide the results of your TB skin test as well as the date on which it was
performed and read. Self-reading by an employee is not acceptable. A TB skin test must have been
performed within the last 90 calendar days. If the TB skin test is positive; a chest x-ray must have been
performed within the last 90 calendar days. A printout with the date of the chest x-ray results and initiation of
treatment as necessary must be documented on the form.

I hereby give consent to have further information requested by Employee Staffing Services released by
the physician who examined me.

Print Name: _______________________________ Signature: ________________________________

Date: ___________________________

TB Test Date Placed: ______________________________

Date Read: _______________________________

Results: ______________________________MM
If Positive Chest X-Ray:
Date Completed: __________________________ Result: ___________________________________

Date TB Prophylaxis Initiated: _________________________________________

MEDICAL LICENSE NUMBER: STATE: ____________________

PRINT NAME: _______________________________________________________________________

M.D. /D.O. SIGNATURE: ___________________________________________________________________

ADDRESS: CITY: _____________________

STATE: ZIP: TELEPHONE #: __________________________________________

FAX #

Revised 6/2017 Page 2 of 2