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Tuberculosis (TB) Contact Follow-up Standard of Practice Evaluation Form: Individual

PHN__________________________

Circle appropriate period

Oct-March

April- Sept

Year

Reviewing Supervisor (name)

Record #1

(Signature)

Date

Calculation of Percentage (%) 19 possible Standard Elements MINUS (-) not applicable (N/A) Elements = Denominator

  • #

    of MET Elements

Total # of Standard Elements (Denominator)

=

%

Reviewing Supervisor (name)

Record #2

(Signature)

Date

Calculation of Percentage (%) 19 possible Standard Elements MINUS (-) not applicable (N/A) Elements = Denominator

  • #

    of MET Elements

Total # of Standard Elements (Denominator)

=

%

Reviewing Supervisor (name)

Record #3

(Signature)____________________________________ Date

Calculation of Percentage (%) 19 possible Standard Elements MINUS (-) not applicable (N/A) Elements = Denominator

Comments:

  • #

    of MET Elements

Total # of Standard Elements (Denominator)

=

%

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

  • #

    of records

© 2007 LAC DPH-Public Health Nursing

F 57

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