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PHN Standards of Practice Evaluation PHNS Tracking Worksheet

)

PHNS

___________________________________

Oct-March

April-Sept

Year________

Individual

Outbreak

Outbreak

STD

Suspects (V)

Contacts

SCF

ACD

HCF

Non-HCF

or Cases (III)

(2)

(1)

(1)

(2)

(2)

(2)

(1)

Jane Doe

II

I

II

II

I

I

PHN Name

ACD

STD

TB

Other

Lead or NB Screening or SIDS

(1)

© 2007 LAC DPH Public Health Nursing

F5

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