Public Health Nursing Practice Manual
Instructions for PHN TB Class 3/5 Assessment Form
Check a proper box as indicated. Refer back to initial referral. Note: Please list site(s) of disease.
Review PHN Practice Manual for priority.
Check box to indicate risk of transmission by the client.
Check whether or not home isolation is indicated.
-15. Self explanatory.
Indicate health needs as they arise: i.e. need for food vouchers, transportation, or any needs related to the client’s health.
Date H290 registration is submitted/initial of person submitting H290 registration.
If applicable, date that H304 of client is submitted/initial of person submitting H304.
Date H289/ interview of index re: contact(s) initiated/initial of person initiating H289.
If H289 initiated, date H304(s) for contact(s) initiated/initial of person initiating H304(s).
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).
Date H289 and dispositioned H304(s) submitted/initial of person submitting H289 and dispositioned H304(s).
Date H290 confirmation or H513 closure submitted/initial of person submitting H290 confirmation or H513 closure. Indicate reason for closure in space provided.
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.
Date education provided/initial of person providing education. Education is to be provided verbally and in writing per TB Program guidelines.
Date education re: communicability and transmission prevention techniques provided/initial of person providing the education.
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