Clinical Service Guide Forms and Teaching Sheets

CSG Forms

• CH-3A Service/Progress Notes
• CH-12 Form Instructions
• CH-12  Misc. Screening and Lab Tests (Rev. July 2015)
• 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 Order Form Instructions
  
• HHS-117 Telephone/Verbal Order
  
• HP 13 Initial Adult
  
• HP 13 Initial Adult (Spanish)
  
• HP 13 Initial (Pediatric)
  
• HP 13 Initial (Pediatric) - Spanish
  
• HP 13 Initial Instructions
  
• HP 14 Interval Adult
  
• HP 14 Interval Adult (Spanish)
  
• HP 14 Interval (Pediatric)
  
• HP 14 Interval (Pediatric) - Spanish
  
• HP 14 Interval Instructions

Cancer 

• ACH-16 Breast Cancer Screening Form
  
• ACH-40 Improving Health for Women (English)
  
• ACH-40 Improving Health for Women (Spanish)
  
• ACH-58 Kentucky Women's Cancer Screening Program Data Collection Form
  
• WH-58 Cancer Screening
  
• WH-58 Minimum Data Elements Training Manual
  
• ACH-100 Mammogram Log (Rev. Jan. 2011)
• ACH-259 (Rev. Jan. 2011) Pap 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 

Sterilization: 

• Sterilization Consent Form
  
• Sterilization Consent Form (Spanish)
  

Growth Charts

• Automated Growth Charts
• Growth Chart Instructions
• MCH-1 Boys birth to 36 months
• MCH-2 Girls birth to 36 months
• MCH-3 Boys 2 to 20 years
• MCH-4 Girls 2 to 20 years

Health Risk Assessments

• ACH-90 Baby, birth to 12 months
• ACH-90 Spanish
• ACH-91 Child 12 months to 6 years
• ACH-91 Spanish
• ACH-92 Child 7 thru 10 years
• ACH-92 Spanish
• ACH-93 Adolescents 11 thru 20 years
• ACH-93 Spanish
• ACH-94 Adults 21 and older, all pregnant, all FP patients
• ACH-94 Spanish
• HRA Instructions (Rev. Jan. 2008)

Hepatitis C

• HCV-1
• HCV-2
• HCV-3

HIV

• HIV Test Form EPID 396
• EWeb HIV Testing Template
• Adult Case Report Form (ACRF)
• Pediatric Case Report For (PCRF)
• HIV and AIDS Knowledge Sheet

 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
• MSDS-2 Nafrinse Tablets
• MSDS-3 Fluoride Varnish
• MSDS White Varnish Omni
• 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
• OH-13 Consent Rework for Fluoride Varnish
• Prevent Tooth Decay Labels
• Prevent Tooth Decay Labels, Spanish

Perinatal Hepatitis B

• EPID-394
• EPID-395
• EPID 399
• PHBP-1
• PHBP-2
• PHBP-3
• PHBP-4
• PHBP-5
• PHBP-6
• PHBP-7
• PHBP-8
• PHBP-9

Prenatal

• ACOG Form A (2003)
• ACOG Form B (2003)
• ACOG Form C (2003)
• ACOG Form D (2003)
• ACOG Form E
• ACOG Form F
• ACOG Form G
• Discharge Postpartum Form
• 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
• PN-3 Exercise in Pregnancy (April 2013)
• 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 (Sept. 2014)

Sexually Transmitted Diseases

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

Tobacco

• T-1 Smoking Counseling Sheet
• T-2 Freedom From Smoking Documentation

Tuberculosis

• TB-1 Infection Form (Rev. July 2018)
• TB-2 Contact Investigation (Rev. July 2018)
• TB-2a Contact Roster Instructions
• TB-2b Contact Investigation Summary
• TB-3 Report of TB Screening
• TB-4 TB Risk Assessment Form (Rev. July 2018) 
• TB-4b Additional Instructions
• TB-5 Candidates for Treatment of Latent Tuberculosis Infection (LTBI) Rev. July 2018
• TB14 KY V-DOT
• 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-25a Electronic References
• 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 Exam vs Breast Self Awareness (optional)
• Breast Self Exam vs Breast Self Awareness - Spanish
  
• Free Breast/Cervical Cancer Screening
  
• Free Breast/Cervical Cancer Screening (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
• Guide to Lowering Blood Pressure
  
• Patient Satisfaction Survey
• Patient Satisfaction Survey, Spanish

• Service Providers and Contact Information
• Safety Plan Pamphlet