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Sudden Infant Death Syndrome Standard of Practice Evaluation Form

PHN__________________________

Circle appropriate period

Oct-March

April- Sept

Year

Reviewing Supervisor (name)

Record #1

Calculation of Percentage (%)

(Signature)

Date

15 possible Standard Elements MINUS (-) not applicable (N/A) Elements = Denominator

  • #

    of MET Elements

Total # of Standard Elements (Denominator)

=

%

Record #2

Reviewing Supervisor (name)

Calculation of Percentage (%)

15 possible Standard Elements MINUS (-) not applicable (N/A) Elements = Denominator

(Signature)

Date

  • #

    of MET Elements

Total # of Standard Elements (Denominator)

=

%

Comments:

Compute average compliance for rating period: Total of percentages =______% (Record percentage on Attachment B under Other SIDS)

  • #

    of records

© 2007 LAC DPH-Public Health Nursing

F 46

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