Public Health Nursing Practice Manual
Instructions for PHN TB Class 3/5 Assessment Form
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Sleeping arrangement: Such as shared bed/room, open/small, closed space. Ventilation (type of ventilation): Such as open windows, forced air ventilation. Neighborhood: Such as dense/multi-unit apartment, single-family dwelling, boarded-up building/homes.
Comments: Add any information that may be pertinent to this case.
Work/ School site:
The objective information may differ from the subjective information obtained from the client’s history. If the work/school sites will not receive contact investigation enter “N/A”. If the work/school investigation is to be done in another district, check referred to district and fill in “Name and CT”. It is not necessary for the referred district to report back to the DPHN of the district re: the industry follow-up. If the industry is in the DOR of the index case district, work/school site objective information should be entered on the form by the PHN(s) of the DOR.
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Work / School e.g., elementary school, continuing education school, office, factory, etc. and # of students/employees at site. School/work space: describe work space/classrooms – indoor/outdoors, opened/closed, small/spacious, proximity to others, etc. Ventilation: open windows, forced air ventilation, available sunlight indoors. Lunch/break area: indoor/outdoors, opened/closed, small/spacious, open window, air conditioning, etc. Personal class space or workstation: indoor/outdoor, opened/closed, small/spacious, open window, proximity to others. Comments: Add any information that may be pertinent to this case.
© 2007 LAC DPH Public Health Nursing