Clinical Service Guide Forms and Teaching Sheets On this page On this page Clinical Service Guide Forms and Teaching Sheets Main Content Local Health Department Medical Abbreviations COVID-19 PEF Documents - Select Clinic Health in the dropdown menuCSG Forms General CH-3A Service/Progress NotesCH-12 Misc. Screening and Lab Tests PerformedCH-23 Authorization for Release/Acquisition of Patient Information (Rev. July 2006) CH-23 Spanish CH-23 Instructions EM-1 Emergency Flow SheetHHS-117 Telephone/Verbal OrderHP 13 Initial PediatricHP 13 Initial Pediatric SpanishHP 13 Initial AdultHP 13 Initial Adult SpanishHP 14 Interval PediatricHP 14 Interval Pediatric SpanishHP 14 Interval Adult CancerWH-16 (formerly known as ACH-16) Breast Cancer Screening FormWH-58 Cancer ScreeningWH-100 (formerly known as ACH-100) Breast Imaging and CBE LogWH-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 HIVHIV 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)RSV Clinical Decision Making Tool 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 DropsOH-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 EntryPrevent Tooth Decay Labels Prevent Tooth Decay Labels, Spanish Prenatal - Please Refer to Bright Futures Website on Updated FormsACH-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 MapEpid-399 Perinatal Hep B Prevention Form for InfantsPHBPP-1: PHBPP Introduction Letter (for the Mother)PHBPP-2: Reminder Letter Prior to DeliveryPHBPP-3: Notification Letter to Hospital about an HBsAg + Pregnant WomanPHBPP-4: Prevention Letter to Exposed Infant's ProviderPHBPP-5: PHBPP for Infants Follow-up FormPHBPP-6: Vaccination Reminder Letter to the Mother PHBPP-7: PVST Reminder Letter to the MotherPHBPP-8: PVST Reminder Letter to the Primary Care ProviderPHBPP-9: Notification Letter to the Mother that Infant is Immune Respiratory PlansPHPS 1 - Employee Fit Test Log PHPS 2 - Employee Fit Test CardPHPS 3 - Respiratory Med Screening QuestionnairePHPS 4 - Rest Fit Test RecordPHPS 5 - Respiratory Storage CleaningPHPS 6 - Employee Competency Verification Reportable Diseases EPID 200 Kentucky Reportable Disease Form (Rev. February 2021) School HealthAppendix A: Epinephrine Auto Injector Protocol in the School SettingAppendix B: Naloxone Protocol in the School SettingAppendix C: Bronchodilator Rescue Inhaler (BRI) Protocol in the School SettingSexually Transmitted Diseases STD-1 Sexual History and Physical Exam Form STD-1 Sexual History and Physical Exam Form (Spanish) TobaccoTobacco Counseling SheetFreedom From Smoking DocumentationTailored Tobacco Treatment Options Tuberculosis TB-1 Infection Form TB-2 Contact InvestigationTB-2a Contact Roster InstructionsTB-2b Contact Investigation Summary TB-3 Report of TB Screening TB-4 TB Risk Assessment FormTB-4a TB Risk Assessment Instructions TB-4b Additional InstructionsTB-4 TB Risk Assessment Form (Spanish)TB-5 Candidates for Treatment of Latent Tuberculosis Infection (LTBI)TB-6 Procedure for the Mantoux TB Skin TestTB-13 Clinic Initial Health Assessment/History /Exam FormTB-14a Consent Form KY V-DOT (Video-Directly Observed Therapy)TB-14a Consent Form KY V-DOT (Spanish)TB-15 Consent Form for KY-DOT (Directly Observed Therapy)TB-15 Consent Form for KY-DOT (Spanish) TB-16 TB Case ManagementTB-16a Nurse Guidelines for Tuberculosis Case ManagementTB-16b TB Case Management Clinical Pathway Checklist TB-17 DOT Record Initial and ContinuationTB-17a DOT Record InitialTB-17b DOT Record ContinuationTB-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 RecordTB-26 TB Clinic Social Service AssessmentTB-26a TB Clinic Social Service Progress NotesTB-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 TSTCSG Teaching Sheets General ACH-10 Improving Health for MenACH-40 Improving Health for Women ACH-40 Improving Health for Women (Spanish)Breast Self-AwarenessBreast Self-Awareness - SpanishMammogram 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/AIDS What You Should Know About HIV/AIDS Spanish Lead MCH-25A Lead Verbal Risk AssessmentLead Case Management FormLead Home Visit Form Oral Health OHEM-4 BrushUp Tips OHEM-4 BrushUp Tips, Spanish OHEM-5 First Aid for Dental InjuryOHEM-7 Mouthguard OHEM-8 Diabetes and Gum Disease Prenatal - Please Refer to Bright Futures Website on Updated InformationParents Guide to Safe SleepWhat Does Safe Sleep Look LikeWhat Does Safe Sleep Look Like (Spanish) MCH-8 Healthier Lifestyles for the Pregnant, Breastfeeding and Postpartum Woman PAM-ACH-8 Spanish TobaccoQuit Tips and Coping with WithdrawalProven Products to Help You QuitCDC | How We Can Protect Our Children from Secondhand Smoke: A Parent Guide Relative Content Additional Information Local Health Department Forms, Documents and Administrative ReferenceNursing OfficeLocal Health Department Information Page Contact Information Related Agencies Department for Public Health Division of Prevention and Quality Improvement Chronic Disease Prevention Branch Health Care Access Branch