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Public Health Nursing Practice Manual

3 Physical Appearance

_______________________________________________________________________________________

Coughing: Affect

no

yes

_________________________________________________________________________

____________________________________________________________________________________________

4 Home Situation house apt. Describe living space shelter hotel or SRO trailer other ___________________________________________ ____________________________________________________________________________________ Describe sleeping space__________________________________________________________________________________ Describe ventilation_____________________________________________________________________________________ Describe availability/amount of sunlight indoor _______________________________________________________________ Describe neighborhood __________________________________________________________________________________ Comments_____________________________________________________________________________________________

5

Work/school site #1

N/A

referred to district

_________________________________

Type of school/work _________________________________________________________________________________ Describe school/workspace ____________________________________________________________________________ Describe ventilation __________________________________________________________________________________ Describe lunch/break room ____________________________________________________________________________ Describe personal class space or work station ______________________________________________________________

N/A referred to district Work/school site #2 Type of school/work ___________________________________ _________ _________________________________________________________________________________ Describe school/workspace ____________________________________________________________________________ Describe ventilation __________________________________________________________________________________ Describe lunch/break room ____________________________________________________________________________ Describe personal class space or work station ______________________________________________________________

N/A referred to district Work/school site #3 Type of school/work _____________________________________ ________ _________________________________________________________________________________ Describe school/workspace ___________________________________________________________________________ Describe ventilation _________________________________________________________________________________ Describe lunch/break room ___________________________________________________________________________ Describe personal class space or work station_____________________________________________________________

Comments/ Date:

____ Initial ____ Initial

______________________

Print Name/Title ______________________

Print Name/Title

_________________________ Signature/Title _________________________ Signature/Title

© 2007 LAC DPH Public Health Nursing

Date/ Initial

E 18

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