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Public Health Nursing Practice Manual

Instructions for PHN TB Class 3/5 Assessment Form





  • 1.

    Check a proper box as indicated. Refer back to initial referral. Note: Please list site(s) of disease.

  • 2.

    Review PHN Practice Manual for priority.

  • 3.

    Check box to indicate risk of transmission by the client.

  • 4.

    Check whether or not home isolation is indicated.

  • 5.

    -15. Self explanatory.

  • 16.

    Indicate health needs as they arise: i.e. need for food vouchers, transportation, or any needs related to the client’s health.

  • 1.

    Date H290 registration is submitted/initial of person submitting H290 registration.

  • 2.

    If applicable, date that H304 of client is submitted/initial of person submitting H304.

  • 3.

    Date H289/ interview of index re: contact(s) initiated/initial of person initiating H289.

  • 4.

    If H289 initiated, date H304(s) for contact(s) initiated/initial of person initiating H304(s).

  • 5.

    If applicable, date H289 and H304(s) of out-of-district contact(s) referred to district of resident/initial of person referring out-of-district contact(s).

  • 6.

    Date H289 and dispositioned H304(s) submitted/initial of person submitting H289 and dispositioned H304(s).

  • 7.

    Date H290 confirmation or H513 closure submitted/initial of person submitting H290 confirmation or H513 closure. Indicate reason for closure in space provided.

  • 8.

    If applicable, date work/school contact follow-up initiated/initial of person initiating work/school contact follow-up. If work/school out-of-district, name of district referred to.

  • 9.

    Date education provided/initial of person providing education. Education is to be provided verbally and in writing per TB Program guidelines.

  • 10.

    Date education re: communicability and transmission prevention techniques provided/initial of person providing the education.

  • 11.

    If applicable, date education re: home isolation provided/initial of person providing home isolation education. Explain to client reason for home isolation, specific precautions he/she needs to take, consequences to self and public if not followed, and who will inform client when he/she no longer requires home isolation.

© 2007 LAC DPH Public Health Nursing

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