Clinical Service Guide Forms and Teaching Sheets

​​​​​​​​​​​​ Local Health Department Medical Abbreviations

COVID-19 PEF Documents - Select Clinic Health in the dropdown menu

CSG Forms

General

• CH-3A Service/Progress Notes
• ​CH-12 Misc. Screening and Lab Tests Performed
  
• CH-23 Authorization for Release/Acquisition of Patient Information (Rev. July 2006)
  
• CH-23 Spanish
• CH-23 Instructions
• EM-1 Emergency Flow Sheet
• HHS-117 Telephone/Verbal Order​
  
• HP 13 Initial Pediatric
  
• HP 13 Initial Pediatric Spanish
  
• HP 13 Initial Adult
  
• HP 13 Initial Adult Spanish​
  
• HP 14 Interval Pediatric
  
• HP 14 Interval Pediatric Spanish
  
• HP 14 Interval Adult​​​
  

Cancer

• WH-16 (formerly known as ACH-16) Breast Cancer Screening Form
  
• WH-58 Cancer Screening
  
• WH-100 (formerly known as ACH-100) Breast Imaging and CBE Log
  
• WH-259 (formerly known as ACH-259) Cervical Cancer Screening Test Log
  

Diabetes

• DSMT-1 Pre/Post Class Feedback Form

Domestic Violence

• DV/SA-1 Domestic Violence/Sexual Assault Documentation Form

Family Planning Forms

• Family Planning Forms

HIV

• HIV Testing Template
  
• Adult Case Report Form (ACRF)
• Pediatric Case Report For (PCRF)
  

Immunization

• CH-2A Immunization Record
• CH-2A Instructions
• IMM-1 Instructions
• IMM-1 Informed Consent for Vaccines
• IMM-1 Informed Consent for Vaccines, Spanish
• What Parents Need to Know - Religious Exemption to Immunizations
• Certificate of Immunization Status (EPID 230)
• Immunization Declination form (EPID 230-A)

Lab

• PHLOK-1 Laboratory Personnel Orientation and Training
• PHLOK-2 Laboratory Personnel Competency Assessment
• PHLOK-3 Sample Clinic Authorized Procedure
• PHLOK-4 Lab Tasks Checklist
• PHLOK-5 Sample QA Worksheet

Lead

• Lead Case Management
  
• Lead Visual Investigative Home Visit
  
• Lead Verbal Risk Assessment
  

Oral Health

• Fluoride Supplies packing slip-order blank (July 2006)
• KIDS SMILES Order form (July 2006)
  
• MSDS-1 Nafrinse Drops
• OH-9 Consent for Fluoride (English and Spanish)
  
• OH-10 Home Water Sample (Jan. 2005)
• OH-10 Spanish (Jan. 2005)
• OH-11 Kids' Smiles (personal record)
• OH-11 Spanish
• OH-12 Dental Screening/Exam Form for School Entry
• Prevent Tooth Decay Labels
  
• Prevent Tooth Decay Labels, Spanish​

Prenatal - Please Refer to Bright Futures Website on Updated Forms

• ACH-282 Prenatal home visit
  
• ACH-283-A Postpartum Home Visit
• ACH-283-B Postpartum Neonatal Home Visit
• PN-1 Consent Form Screening for Cystic Fibrosis (April 2013)
• PN-1 Consent Form Screening for Cystic Fibrosis, Spanish
• PN-2 Pregnancy Health Risk Screen (Rev July 2017)
• KY Moms Referral Form
• KY Moms Service Map
• Epid-399 Perinatal Hep B Prevention Form for Infants
  

Respiratory Plans

• PHPS 1 - Employee Fit Test Log​
• PHPS 2 - Employee Fit Test Card
• PHPS 3 - Respiratory Med Screening Questionnaire
• PHPS 4 - Rest Fit Test Record
• PHPS 5 - Respiratory Storage Cleaning
• PHPS 6 - Employee Competency Verifcation

Reportable Diseases

• EPID 200 Kentucky Reportable Disease Form (Rev. February 2021)
  

Sexually Transmitted Diseases

• STD-1 Sexual History and Physical Exam Form
• STD-1 Sexual History and Physical Exam Form (Spanish)

Tobacco

• Tobacco Counseling Sheet
  
• Freedom From Smoking Documentation
  
• Tailored Tobacco Treatment Options
  

Tuberculosis

• TB-1 Infection Form
  
• TB-2 Contact Investigation
  
• TB-2a Contact Roster Instructions
• TB-2b Contact Investigation Summary
• TB-3 Report of TB Screening​
  
• TB-4 TB Risk Assessment Form
  
• TB-4a TB Risk Assessment Instructions
  
• TB-4b Additional Instructions
  
• TB-5 Candidates for Treatment of Latent Tuberculosis Infection (LTBI)
  
• TB-6 Procedure for the Mantoux TB Skin Test
  
• TB-13 Clinic Initial Health Assessment/History /Exam Form
  
• TB-14a Consent Form KY V-DOT (Video-Directly Observed Therapy)​
  
• TB-15 Consent Form for KY-DOT (Directly Observed Therapy)
  
• TB-16 TB Case Management
• TB-16a Nurse Guidelines for Tuberculosis Case Management
• TB-16b TB Case Management Clinical Pathway Checklist
• TB-17 DOT Record Initial and Continuation
• TB-17a DOT Record Initial
• TB-17b DOT Record Continuation
• TB-17c DOT Tracking Record (Missed Doses)
• TB 17d Clinic DOPT Record Continuation
• TB-18 Bacteriology Report
  
• TB-19 TB Surveillance Report
  
• TB-20 TB Clinic Follow-up Visit
  
• TB-21 TB Clinic Referral Form
• TB-22 TB Clinic Physician/APRN Orders
• TB-23 TB Chronic Medication List
• TB-24 TB Clinic Progress Notes
• TB-25 TB Clinic Education Counseling Record
  
• TB-26 TB Clinic Social Service Assessment
  
• TB-26a TB Clinic Social Service Progress Notes
• ​TB-26b TB Clinic Social Services Care Plan
• TB-27 Activities for Providing DOT for Outreach Workers
  
• TB-28 Prioritization of Contacts
  
• TB-29 TB Disease Treatment Cards
• TB-30 LTBI Treatment Cards
• TB-31 Incentives and Enabler Request
• TB-32 LHD TB Monthly Report
• Procedure for TST

CSG Teaching Sheets

General

• ACH-10 Improving Health for Men
  
• ACH-40 Improving Health for Women 
  
• ACH-40 Improving Health for Women (Spanish)​
  
• Breast Self Awareness
  
• Breast Self Awareness - Spanish​
  
• Mammogram Benefits and Risks (optional)
  
• Mammogram Benefits and Risks - Spanish
• GPEM-1 Safe Options for Home Needle Disposal
• GPEM-2 Proper Disposal of Prescription Drugs
  

Domestic Violence

• Service Providers and Contact Information
  

Family Planning Teaching Sheets

• Family Planning Teaching Sheets

Hepatitis C

• HCV Links to Teaching Sheets

HIV

• What You Should Know About HIV/AID
• What You Should Know About HIV/AIDS Spanish​
  

Lead

• MCH-25A Lead Verbal Risk Assessment
  
• Lead Case Management Form
  
• Lead Home Visit Form
  

Oral Health

• OHEM-4 BrushUp Tips
• OHEM-4 BrushUp Tips, Spanish
• OHEM-5 First Aid for Dental Injury
• OHEM-7 Mouthguard
  
• OHEM-8 Diabetes and Gum Disease

​ Prenatal - Please Refer to Bright Futures Website on Updated Information

• Parents Guide to Safe Sleep
  
• What Does Safe Sleep Look Like
  
• What Does Safe Sleep Look Like (Spanish)​
  
• MCH-8 Healthier Lifestyles for the Pregnant, Breastfeeding and Postpartum Woman
• PAM-ACH-8 Spanish
  

Tobacco

• Quit Tips and Coping with Withdrawal
  
• Proven Products to Help You Quit
  
• CDC | How We Can Protect Our Children from Secondhand Smoke: A Parent Guide​
  

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