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ANM Name/SPA

ACD

STD

TB

Other

Total Average %

Individual ACD

Outbreak HCF

Outbreak Non-HCF

STD

Suspect (V) or Case (III)

Contacts

SCF

Lead or NB Screening or SIDS

Jane Doe

100%

95%

80%

100%

95%

100%

100%

90%

95%

PHN Standards of Practice Evaluation Nursing Director Summary

Oct-March

April-Sept

(Attachment E)

Year

_________

Countywide compliance %

© 2007 LAC DPH Public Health Nursing

F9

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