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Individual PHN Evaluation of Practice Summary Workshe (Attachment B)

Individual

Outbreak

Outbreak

ACD

HCF

Non-HCF

PHN

PHNS

ACD

STD

Oct-March

TB

April-Sept

Other

STD

Suspect (V) or Case (III)

Contacts

SCF

Lead or NB Screening or SID

(print)

(print)

Total Average %

Year

_________

Supervisor's Comments:

PHN's Comments:

Goal/Stategies for Maintenance of Effort or Improvement:

P H N S i g n a t u r e _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Date:

_______________

PHNS Signature

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Date:

_______________

PHN Received copy of this form: PHNS Signature ___________________________________

Date:

_______________

© 2007 LAC DPH Public Health Nursing

F6

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