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Acute Communicable Diseases Standard of Practice Evaluation Form: Outbreak in a Non-Healthcare Facility/Agency

PHN

__________________________

Circle appropriate period

Oct-March

April- Sept

Year

STANDARD ELEMENTS

RECORD #

RECORD #

(1)

(2)

COMMENTS

ASSESSMENT

  • 1.

    Documentation reflects that referral was reviewed as indicated by:

    • Date/Time/Signature on referral when received from PHNS (p. C14).

  • 2.

    Analyzes the report per PHN Practice Manual

      • (p.

        C14) as demonstrated by the completeness or incompleteness of the data.

    • Indicates that all data was complete or follows up on missing data, if needed.

COMMENTS:

MET

NOT MET

N/A

MET

NOT MET

N/A

© 2007 LAC DPH-Public Health Nursing

F 22

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