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Tuberculosis (TB) Source Case Finding in a Documented Converter Standard of Practice Evaluation Form

PHN__________________________

Circle appropriate period

Oct-March

April- Sept

Year

Reviewing Supervisor (name)

Record #1

(Signature)____________________________________ Date

Calculation of Percentage (%) 18 possible Standard Elements MINUS (-) not applicable (N/A) Elements = Denominator

  • #

    of MET Elements

Total # of Standard Elements (Denominator)

=

%

Record #2

Reviewing Supervisor (name)

(Signature)____________________________________ Date

Calculation of Percentage (%) 18possible Standard Elements MINUS (-) not applicable (N/A) Elements = Denominator

Reviewing Supervisor (name)

  • #

    of MET Elements

Total # of Standard Elements (Denominator)

=

%

Record #3

(Signature)____________________________________ Date

Calculation of Percentage (%) 18 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 SCF)

  • #

    of records

© 2007 LAC DPH-Public Health Nursing

F 62

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