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91-1842��v`�-`�- Y ��Council File � ��- D k d � / �•__/ Green Sheet � 6375 RESOLUTION . CITY OF SA T PAUL, MINNESOTA . , Presented By � • Referred To Committee: Date SAINT PAUL BOARD OF HEALTH WHBREAS, the City of St. Paul through its' Division of Public Health has chosen to submit a Refugee Health Grant to the Minnesota Department of Health to monitor completion of screening of newly arrived refugees; and WHEREAS, the Board of Health will be required. to approve up coming contracts between the Minnesota Department of Health and the City of St. Paul Division of Public Health. THEREFORE, BE IT RESOLVED, that the City Council sitting as the Board of Health does accept and approve the Refugee Health Grant for 10-1-91 through 9-30-93 for St. Paul. Yeas Navs l,bsent gequested by Department of: � J Commun Se ices � � � � By. !l� .� Adoptsd by Council: Date ��T i `' �� Form Appr ed by C'ity Attorn y r Adoption Ce if by Council ecretary gy: - �j , Z _ - �. $Y= Approved by Mayor tor Submissfon to Approved by ors Date _ OCT � 5 �J91 Council QG�ti� , gy; �d��-' , BYs Pt�USHEO OCT 19°91 . -� ; �r-,�� DEPARTMENTlOfFICE/COt1NpL DATE INITIATED c.s./Public Health 9/10/91 GREEN SHEEI` No. 0^375 OONTACT PERSON R PHONE� ��T��T� INITIAUOATE �ARTMENT DIRECTOR �CITY OWNpI: Diane Holmgren 292-7712 �� ATTORNEY CITY CLERK �, " MUST BE ON COUNqL A4ENOA BY(DATEj ROUTINO BUOOET DIRECTOR � �FIN.6 MOT.BERVICES pR. Scheduled f or October 1, 1991 0�u►voR coa�ssisr�wn TOTAL i OF SIGNATURE PAGES � , (CLIP ALL LOCATIONS FOR SIGNATUR� ACTION REOUESTED: City signatures on a Resolution for Board of Health approval of various grants to the , Minnesota Department of Health by the St. .Paul Division of Publ�c', Health. REOOMMENDATIONS:MP►�W a�1�l� , COUNCII COMM11rTEElRE8EARC11 REPORT OPTIONA _PLANNINfi OOMMISSION _qVIL SERVIC�WMMISSION ANALYST PHONE NO. VED _d8 f�MIMITTEE _ ( � _BTAff _ COAAMENTS: ��.�`: !f.,roY#.�.�f '� SEP j 1 1991 . _018TRICT OOURT _ �"-�''�`r : ��,��.�� ` CITY ATTO . INfYIATINO PR08lEM�ISSUE�OPPORTUNITY(Wfq.WMt.WF�n.WlMts.�Nh�: The City.of St. Paul, Division of Public Health requests Board of �iealth approval of grant proposals to the Minnesota Department of Health for funding including: - Maternal and Child Health for 1992-1993 ($1,645,862) ' - WIC (Women, Infants and Children) Supplemental Food Program for';10/1/92-9/30/93 ($2,325,00 ) - Refugee Health (Dionitoring Program) for 10/1/92-9/30/93 ($49,270) � ADVMITACiE8 IF APPROVED: . ' The City, Division of Public Health will receive approximately $4,Q20,132 to support these programs and activities. � � ; . . . , . RECEIVED . _ , � ; . . � : - � . . � ' �� ` , r , . . , : : . . , �.,. -.. _ ; _ SEP 2 6 1991 , . : � . . _ . w � ::. , !1 : . ; t DISADVMIT/UiE3 IF APPROVED: , : ,: -. _,:� ! : �;�: . . . .. ':� :; NoNE - �. . . . . � RcCE1VED : . `SEP 2 0 1991 .., � .; :-MA1�OR'S OFFIC� . � d8ADVANTAOEB IF NOT APPROVED: ; . . . -. . , . , �_ , , t ,. , . � . - ., __ � . . , � .- -�.. . .. .,., . ,,.. , .. : . .. . . The City of St. Paul, Division of Public Health may� not receive .full funding for these activities _ :CQUnCI� ReS�a��►: r;ar��r . . : . - SEP 2� 1991 � � TOTAL AMOUNT OF TRANSACTION = 4,020,132 COST/REVENUE�SUDOETED(CI�ON� O . NO • ,_ � ' { �oiNa sp�t� State of Minnesota ��N�M�RVarious ' FiP1At�ICIAL INFORMATION:(EXPIAII� , , ';j r : ' i , i . . . 'r - �, r� 9,_ ��- CITY OF SAINT PAUL 'iii`i i'`ii � ; OFFICE OF THE CITY COUNCIL PAULA MACCABEE susatv ooE Councilmember Legislative Aide , Members: • Paula Maccabee, Chair Bob Long Janice Rettman Date: October 9, 1991 COMMITTEE REPORT HUMAN SERVICES, REGULATED INDUSTRtES AND RULES AND POLICY COMMITTEE 1. Approval of the minutes of the Human Services, Regulated Industries, and Rules & Policy Committee for: August 14, 1991; August 28, 1991; and September 11, 1991. COMMITTEE APPROVED, 3-0 2. Resolutions �referred from the Board of Health (Referred 10-1-91) : A. Resolution 91-1842 - approving Refugee Health Grant for F.Y. 1992 - F.Y. 1993. COMMITTEE RECOMMENDED APPROVAL, 3-0 B. Resolution 91-1843 - approving 1992-1995 St. Paul-Ramsey County Community Health Services Plan,a nd the 1992-1993 Indian Health Grant for St. Paul and Suburban Ramsey County. COMMITTEE RECOMMENDED APPROVAL AS AMENDED, 3-0 C. Resolution 91-1844 - approving 1992-1993 Maternal Child Health Plan for St. Paul . COMMITTEE RECOMMENDED APPROVAL, 3-0 _ D. Resolution 91-1845 - approving F.Y. 1992 - F.Y. 1993 Application for Administration of Local W. I.C. (Women, Infants and Children) Project. COMMITTEE RECOMMENDED APPROVAL, 3-0 3. Ordinance - amending Chapter 318 of the Legislative Code relating to Mechanical Amusement Devices (Last in Committee 9-25-91) . THIS ISSUE WAS LAID OVER TO THE OCTOBER 23, 1991, HUMAN SERVICES, REGULATED INDUSTRIES, AND RULES AND POLICY COMMITTEE MEETING CITY HALL ' SEVENTH FLOOR SAINT PAUL, MINNESOTA 55102 612/298-5378 5�46 Printed on Recycled Paper , ^ �/--/��- AGENDA OF THE SAINT PAUL CITY COUNCIL BOARD OF HEALTH Tuesday, October 1, 1991 Council Chambers Third Floor City Hall and Court House Molly O'Rourke, City Cierk v1. Resolution - 91-1843 - approving 1992-1995 St. Paul-Ramsey County Community Health Services Plan, and the 1992-1993 Indian Health Grant for St. Paul and Suburban Rams�y County. � Resolution - 91-1844 - approving 1992-1993 Maternal and Child Health Plan for St. Paul. (/3. Resolution - 91-1845 - approving F.Y. 1992 - F.Y. 1993 Application for Administration of Local W.I.C. (Women, Infants and Children) Project. V4. Resolution - 91-1842 - approving Refugee Health Grant For F. Y. 1992 - F.Y. 1993. , . �. �.Q�_�d�� REFUGEE HEALTH GRANT SAI NT PAUL D I V I S I ON OF FUBL I C HEALTH October 1 � 1991 - September 30 � 1993 JULY 31, 1991 � � � ��-/��a REFUGEE HEALTH GRANT TABLB OF CAATENTS FaceSheet .... .. .. ... . ........ ..... ... i Project Information ... ... . . ....... . .. . ii Goal .. ... .. . ... ..... .... . ... ... . .... 1 Objectives/Itarrative .. . . . .. .... . . . ... . 1-4 Budqet Request .... ... . ... . .... . . .. . . . . S Budqet Request Supplea�ent . ..... . . . . .. . 6 4iorker's Compensation . ... .. ... ... . . .. . 7 Non-Profit Status .. . .... .. . . .. . . .. . . . 8 Tuberculosis Standinq Orders .. . .. . . .. . Attachment A Refuqee Health Screeninq Form .. . . .. .. . Attachment B � • 1 . ��J /� �� :� MINNESOTA DEPARTI�tENT OF HFALTH ' Face S6eet . Grant Applicatioa For (1) REFUGEE T3EALTIi Name of Grant 2 APPLICANT AGENCY with ahich contrad is to be execute Legal Name Address Phone(include area code) Saint Paul Division of 555 Cedar Street Public Health Saint Paul, Minnesota 55101 (612) 292-7712 3 DIRECTOR OF APPLICANT AGENCY Name/Title Address . Phone (include azea code) Katherine C�irns 555 Cedar Street Public Health Birector Saint Paul, Minnesota 55101 (612) 292-7712 4 FISCAL MANAGEMENT OFFICER OF APPLICANT AGENCY Name�fle Address Phone(include area code) Katherine Caims 555 �Cedar Street Public Health Director Saint Paul, Minnesota 55101 (612) 292-7712 OPERA'TII�IG AGENCY if different from number 2 Name/T'ide Address . Phone(include area code) CONTAGT PERSON FOR OPERATIIJG AGENCY if different from number 3 Name�de Address � Phone(include azea code) CONTACT PERSON FOR FCTRTHER INFORMATTON ON APPLICATION if different from number Name�de Address Phone(include area code) Carolyn Weber 555 Cedar Street � ' Clinical Program Manager Saint Paul, Minnesota 55101 (612) 292-7731 (8) COPIES OF THIS APPLICATION HAVE BEEN SENT TO THE FOLLOWII�IG REVIEW AGENCIES: _ - AGFNCY TYPE AGENCY NAME(S) Metropolitan Council Date sent Re�onal Development Metro quare • ui ing . Commission(s) Saint Paul, Minnesota 55101 July 31, 1991 Community Hcalth Boud(s) --N/A if the Board is - the Agpticaat- (9) I certify that tbe information contained herein is we and accurate to tbe best of my knowledge and that I submit this applicadoa oa behalf of the applicant agenry. _ . Sig¢ature of Director of Applicant Agency: ' - Tide: Public Aealth Director • Date: 7i31i91 - __ HE-01274-02(3/15/91) � � �-i- : � � MINNESpTA LEPART:�fENT OF HFALTH �/�� PROJECT I,'�1FOR1�tATION � � �1� RF.FfT[:F.F. HFAT TH � (Name of Grant) � (2) PROJECT INFpRMqTION APPLICANT AGENCY � Saint Paul Division of Public Aealth - 555 Cedar Street BEGINNII�TG DATE END DATE PROJECT FUNDS REQUES'TED October 1, 1991 September 30, 1993 Y��1 Year 2 SERYICE ARFA(City,Couary,or Counties) LOCqI,MqTCH PROVIDED Year 1 � Year 2 Ramsey County � MN TAX I.D.# 802-5095 . � FED.I.D.� (if applicable) 41-600 5521 (3) NON-PROFI'T r_rATr�c• � �1•a �PY a��: Yes Not Applicable R - letter attached (4) EVIDENCE oF WORI�RS• COMPENCArrnN INCt m A � Attacbed: Yes R �No Not Applicable Unit of local government (� A�MATIVE ACTION• The agency has a certificate from the Commissioner of Human Rights, pursuant to Minnesota Statutes, Seciion 363.0?3: � Attached: Yes No _ X _ _ -- _ Not Applicable beause: a. Total conUact is SS0,000 or less b. Agenry has 20 or fewer!ull-cime employees � R Units of local government d Indiaa reservations . -ii- , � � �/-/�� REFUGEE HEAL TH GRANT APFL I CAT I ON SAI NT PAUL D I V I S I ON �F PUBL I C HEALTH GOAL : To provide health screeninq ta neWlp arrived refuqees in Ramsey Cauntp and to facilitate transfer into onqoinq sources of health care in the caAUnunity. 0�'PRESCS OBJBClIVE 1 - To notify neWly arrived refuqees of the need for a health assessment. MB'lHODS: - Qpan receigt of a capy af the ACVA form from the Minnesata Department of Health (MDH), each refugee or sponsor �ill be contacted Within one Week by a bilingual health and education assistant to: 1) verify arrival 2) notify them of the need for a health assessment 3) determine the chaice of lacation for health screening If screeninq choice is: 1) Division of Public Health, a screeninq appointment is made Within three weeks. Refuqees are screened at 555 Cedar Street, Saint Paul, Minnesata 55101. SPDPH is currently screeninq about 70� of all newly arrived refugees ta Ramsey County for whom ACVA forms are received. 2) Anather health provider, ACVA fortns and accampanying forms for each individual are forwarded to that provider. The graviders are instructed to return the completed ACVA forms ta the SPDPH. 3) Forms for those refuqees Who have moved aut of the local - area are returned to !!DH to update information and forward to the graper jurisdiction. INDICATORS: - Number of ACVA fornrs received during quarter - Nwnber of refugees screened at SPDPH - Nim�ber screened by other agencies HBAL?S CARE S�tV I CBS OBJBCPIVE 2 - Ta provide ta newly arrived refugees, a comprehensive medical examination f or clinicallp apparent problems, such as malnutrition or anemia, screening for infectious diseases and a determinatioa of their qeneral health status. METHOD: - Services Will be pravided bp physicians, nurses, and ather allied health staff. -1- � . ' ' HB�LTH CARE SffitYICES �//�7d� OBJBt,TIVB 2 - l�TSOB: Cantinued - Services pravided �ill include: o Health History o Phpsical examination 0 Labaratarp tests, includinq hemoglobin, urinalysis, HBsAq, care antibody, anti-HBs, stool specimen analysis for parasites, and for children under five, ferritin, hematocrit, ZEF and micro blaods. 0 Hearinq and visiaa screeninq 0 Tuberculia evaluation o Nutritional evaluation aad referral o Dental evaluation and referral o Inmiuniaatians 0 Ref erral to autside providers or SPDPH pria►ary care clinic f ar on-qoing or specialtp care - Refuqees are stronqly beiaq encouraqed to applp f or Hedical Assistance and this is the primarp source o� papment far services. In certain limited circuntistances, local sponsors have paid for grecedures. - Full docwnentation of all grocedures, findinqs, and treatments, includinq certain test results and conditians will be recarded on a personal health record card that is qiven to the refugee. I l(DI CATORS: - Nwnber of refuqees screened - Number of services grovided includinq health histories, ghpsical egams, laboratary tests, hearinq and vision screening, mantoux tests, x-rays, nutritional evaluations, dental evaluations, i�nnunizations - Number af referrals TQBERCIILOSI S - OB3ECTIVE 3 - To assure that refuqees in need- �of preventive theragy far tuberculosis are placed on such therapy and monitored for � campliance. METHODS: - Mantauxs are administered to all refuqees as gart of their initial screeninq. - If patient has pasitive mantaux, chest x-ray is taken and if na gatholoqy they are put on preventive therapy under standinq orders. They are manitored by physician and nursing staff through office follaw-up and home visits. {SEE ATTACHMENT A) - If a-rap shows gathalogy, they are treated accordinq ta physicians deternunation af treatmeat. INDICATORS: - Nvmber of mantauxs administered - Number of positive mantouxs - Nwnber with tuberculasis infection - Number started an preventive therapy -2- ' "HBPl�?ITIS B �'1��c� OBdSCTIYE 4 - Ta assure that all refuqees are screened for HBV carrier status and that newborns and susceptible household contacts are vaccinated. METHODS: - All refuqees aqe 3 years and older havinq appointments at SPDPH Refuqee Screeninq Clinic are screened for Hepatitis B surface antiqen and core antibody status. If family member tests positive, those children under aqe 3 are alsa tested. Based on test results, susceptibles in familp are qiven a series of Hepatitis B Vaccine (HBV) . Fo11aW-up is maintained throuqh Refuqee Clinic and/or Imtnunizatian Proqram trackinq system ta ensure campletion of the HBV series. HBV series started averseas are continued ta completian at SPDPH. Anti-HBs are drarm at three manths to ascertain effectiveness. IIIDIC�TORS: - Nwnber of Sepatitis B immunizations qiven - Number of susceptible household contacts to hepatitis B carrier f emal es - Number vaccinated M01(ITORIXG l�I�D FOLLOfi-QP OBJECTIVE 5 - Monitorinq and fallow-up will be provided ta ascertain that screeninq is completed and that conditions necessitatinq continuinq care are f allowed. METHODS: - Refuqees receivinq screeninq at SPDPH are scheduled for any necessary follow-up visits for up ta ane year after screeninq to resolve any problems befare being referred ta other praviders far an-gainq care. Clients failinq apgointments are contacted by phane and/or letter and rescheduled. - Healt� groblems requirinq additianal care are referred to either internal SPDPH proqrams which address the need or ta ather providers in the canununitp. Clinics at Ramsey Medical Center, Bethesda Familp Practice, and Childrens Hospital are - - most frequeatlp used for referral of health problems. - --� _ - Clients siqn a release of information in order for reports to be sent back ta SPBPH. - Clinic staff make apgointments and staff bilinquals call ta . remind clients of the upcominq appointments. - Information xhich documents the result of each refuqee's health assessment �ill be recorded on the "Refugee Health Screeninq and Fallaw-ug Informatian" form and submitted to MDH within 90 daps af arrival . - Monitorinq of these activities will be provided by a Health and Education Assistant - Hmonq (Blia Vang) , supervised by Refuqee Froqram Manaqer. Il�(DICATORS: - Number af refuqees screened - Nwnber of refuqees referred - Number of farms sent to 14D8 � -3- . BILIXGUIlLS �� SPDPH currently has bilinqual staff (3.0 FTE) to translate Emonq is 91$ of our current client load. Sponsors are responsible for providinq interpreter services for other lanquaqes. Volunteer translators are avai2able in tbe coumunity for anerqencies. The Citp of Saint Paul maintains a list of city emplapees xith lanquaqe skills besides Enqlish and are called upan if necessary. SPDPH bilingual staff provide interpretinq services for the Tuberculosis Control and Immunisatioa Proqrams (includinq Hegatitis B) as xell as havinq clinical duties. VOI.SGS The Bealth and Educatian Assistant contacts VOLAGS to obtain locatiag information far refuqees and sponsors if informatian is not on farm. Sponsors are contacted ta assist in makinq appointments for screeninq. At the clinical leve2, the nurse has direct contact With the VOLAG person active With a particular patient. The Proqram Manaqer is ia contact With VOLAGS if unusual prablems or situations arise. - CW/am � 7/30/91 _ _ _ _ _ -4- . � 2 � + } � �► E �. c • ' ~ f ~ ~ � va• • ¢ O V W �� f. d N W U a rE . < • I ao � 2 � a W a�if L m ! 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C � �o � Oi •+ S y E � O � A � � �A Cj � •m O �O tn r � O E ` � u�i Z Z � � ` " "' ` � ~ m C e~o C m t�0 �p 1L ` � � I.L � � N � M t N t � Z 61 � C ' d 'o � �i $ � w � � � J � c � m �o" o �, � O `° � O a� t� y 'ti •' io R W C1 J U t� ,r. .,, � � ie y � O � �? � � > a � C L r E . �• � m ^ C�i .. a � a` 'p' ,� c ` « �, � d � o _ H � � ,� M � � to 7 �a O O � y • � gt L V� H c� a U O 1- cn Q m V C U _ 3 a tL c +L-' °i ° a�i To � � � «��. O N � ti Z F- a` ii Q m U 0 W ti — _ r " vaiiiV ♦d41 LiY1.7jV11 VL L1.{V1j{,;. L1CQ,LL(1 555 Cedar Street Saint Paul, Minnesota 55101 ��r��-- , SIIIKElE1R 10 tt�OC�ET �EQuEST/EtIE1101iYRE �E1pRT . - . � y�tAar Ah0 F4iMCE , •NNVA� NO TQTA� NAME ANO SA�A11Y MOS ♦TtME AMONNT �fIT10NT�T�E 1�ATE •uOG �EOV�wEO � 111 1:1 1)1 1�1 Blia Vang, Health b Education Assistant 24,635 24 100X 49,270 (annual salary rate is for 1991, a 2X cost of living increase is for both 1992 and 1993 which is reflected - in the total amount) i11�NGE �ENEFITSfII�t�— 26X � �`'. "~ L '.I CATEGOiiV TOTAI s 49 270 —6— . . . � - �'//�� _ � EVIDENCE OF COMPLIANCE - " - � State law forbids the Comiaissioner ot Health froa enterinq into any contract until the Commissioner receives acceptable evidence of compliance with workers' compensation insurance coveraqe _ : requirements from the contractor. The exception to this _ requirement is a self-employed contractor who has no e^ployees. - - An employee, as defined by Minn. -Stat. 176.011; subd. 9, is any - -- -- person who perfor�s services for another for hire, including �inors and family members. � If you do not fall within the exception- and you wish to enter- -- - � into a contract with the Commissioner of Health, you can furnish acceptable evidence of compliance with workers' cor►pensation coverage in any one of the followinq four ways: - � � Z. Attach a certificate of insurance (supplied by you workers' � compensation carrier) to this Exhibit; or ZI. If you are self-insured, attached a written order from the Minnesota Commissioner of Commerce allowinq you to self- � _ _- insure to this Exhibit; or " III. If you are self-insured and you are a state agency or a =� municipal subdivision of the state, pursuant to Minn. Stat. 176. 181, subd. 2, and are not required to obtain a - written order from the Commissioner of Commerce, circle this ' entire item and sign and date the form below in the space . provided; or - IV. Fill in the information for each item below and sign in the space provided: A. Name of Contractor's insurance carrier: _. _ B. Address of Contractor's _insurance carrier: _ _ _ _ _ C. Contractor's insurance policy number: D. I affirm that all the employees of . (Contractor's Name) are covered by the workers' compensation insurance policy listed above. � C�` , Siqned by: �Q � Title: Public Sealth Director . Date: Julq 31, 1991 -7- • N�N—PR�F I T STATtJ S - _ • - �'/��a� �..n., � CITY OF SAINT PAUL '� = DEPARTMENT OF COMMUNITY SERVICES : ; �. ,c DIVISION OF PUBLIC HEACTH .... 555 Cedar Street,Saint Paul,Minnesota 55101 (612)292-7711 1MAE5 SCFIEiea MAYOR Saint Paul Division af Public Health is a governmental arganizatian �hich is tax eaempt. MIriI(BSOTA TAX I.D. I(Ql��t: 802-5Q95 FSDERAL �lPLOYBR I.D. IIII!lBBR: 41-60055521 July 31, 1991 -8- N�! � • � Attachment A g�l0 �� TtJBSRCUL082 S C011TROL • . ' �� - � STIINDI110 ORDERS ``. : Isoniasid �INB) Preventive Therapl For perscns under 35 pears af �ho: 1. Have a positive mantou= test and a normal chest a-ray. 2. Are household contacts of a knoWn case of Tuberculosis Who have a positive mantoux test and normal chest x-ray. (See paqe 3 for interpretation of mantoux reactions) � Y�S3T M�DL�,dTZOH 0.'�ER $8$ PAYSICI111( $�$� 1ST INH CBC �ith NO 1 month lOmq/kq/dap up differential , UA to 300mq/dap �ith Hicro, CXR 2ND Refill INH Rx Check for anp side YES 1-2 manths for 1-2 months effects 3RD S Refill INH Rx Check for anp side If indicated Every 1-2 __ subsequent for 1-2 months effects months � visits for 6- - 12 months as ordered by physician Last month's Refill INH if indicated if indicated Give card if visit completed Schedule patients Who miss appaintments or doses to retum ance a month. ' Schedule patients, taho the nurse feels should be seen more frequentlp'tFian-u►onthly, back to se the physician. �QNTR8�IN1tL�T�QN3_= l. Frevious isoniazid-associated hepatic injury. 2. Severe adverse reactions to isoniazid, such as druq fever, chills 5 arthritis. PRECAUTIONS: Carefully monitor patients xho: 1. Are receivinq phenptoin concurrently. (dilantin) 2. Are dailp users of alcohol . 3. Have current chronic liver disease or severe renal dpsfunetion. . 4. Have visual spmptoms while on INH. 5. Since INH is known ta cross the placental barrier and to pass into maternal breast �:�= milk, neonates and breast-fed infants of INH treated mothers should be carefullp _ observed far any evideace of adverse effects. I�ev�ewed �c.v�d 12e�,��d a/�t� Minnesota Department of Health GJ/� �j � ,�„ � r Refugee Health Unit U.S. Anival Dat .e� ��-! � 717 Delaware Street SE � � P.O. BOX 9441 Month Oay Ysar Minneapolis, MN 55440 Forms Received at MDH: � (61�623-5237 / / Mo�th Oay Year REFUGEE HEALTH SCREENING AND FOLLOW-UP INFORMATION NAME(last,first,middie) DATE OF BIRTH(month,day,ysa� Alien or Visa Registration N (from ACVA form) . 1. Date of Care(for services indicated below): I I Month Day Year 2. Immunization Record: DTP/Td I l l 1 / Mo. Yr. Mo. Yr. Mo. Yr. Mo. Yr. Mo. Yr. POliO l 1 I I Mo. Yr. Mo. Yr. Mo. Yr. Mo. Yr. Measles / Mumps / Rubella I Mo. Yr. Mo. Yr. Mo. Yr. 3. Tuberculosis Screening: Chest X-Ray: Chemotherapy and Chemoprophytaxis Tuberculin Skin Test (taken in U.S.) 1. � Infected without disease- prophylaxis prescribed 1. � PPD 0-4 mm 1. � Normal 2. ❑ Infected without disease- no prophylaxis 2. ❑ PPD 5-9mm 2 ❑ Abnormal prescribed; explain 3. � PPD 10-14mm 3. 0 Suspected tuberculosis disease -chemotherapy 4. � PPD� 15mm prescribed 4. ❑ Tuberculosis disease-chemotherapy prescribed 4. Hepatitis B Screening HBIG/HBV Vaccine Record 1. � HBsAg negative a. ❑ Anti-HBs negative HBIG / b. ❑ Anti-HBs positive Mo. Yr. 2. ❑ HBsAg positive HBV Vaccine I I l - - - _ Mo. Yr. Mo. Yr. Mo._ Yr. 5. Screened for parasites: 0 Yes 0 No - - - If POSITIVE, check parasite(s)found: ❑ Ascaris 0 Trichuris ❑ Clonorchis ❑ Strongyloides ❑ Schistosomiasis O Hookworm ❑ Giardia ❑ Aragonimus � Amoebic Dysentery 0 Other. 6. Currently Pregnant: ❑ Yes ❑ No 7. ECG Administered: ❑ Yes ❑ No 8• h1EIGHT(inches) WEIGHT(ibs.) HEMOGLOBIN HEMATOCRIT �� . AGENCY,CIINIC or PHYSICIAN PflOViDING SERVICE COMMENTS STREET ADDRESS CITY,STATE,ZIP. ►Please retum completed torm wfthin 30 days.Thank you. - _ . Distr/Dutfon:White—MOH Re/ugst Health UMf i Canary—Loea/Healfh AQeney _ � HE-01198-02 ( STATfJffi�1T OP RIGHT3: Infosaation on tnis tors is oollecsea sos cae ' Minn�sota Department of Health (I�H), by autlwrity of Section {12 ' fcx3) of tde Lvigration and Natioeality Act as amended by the y � + It�lugee 1►ct of 1960. ?dis information is used to obtain a health - " -- — - - - rvaluation and/or tresteent for tt�e patient and to facilitate the individuals•s enrollsent inLO a school or day cart eenter as requir�d _ by N.S.S 123.�0. 111though there is no legal obligation to provide tl�is infonation, refusal say sesult in delay of s�rvices or denial . of ensollsent into a Mitu►esota school or day care center. In order to provide serviess, it say be necessary to celeaae information iram _ tde patient's record to individuals or agencies vho are inwlved in . the care of tt�e individual. Such individuala and agencies usually � , include lamily physicians a�d/or dentists, aedical and dental special- ists, puDlfc Aealth agencies, hoapitais, sehools, and day care centess. , All public health agencies, health 3nstitutions, oc pcaviders to whow _ the sefugee has appeaced for treatment or services shall De entitled to the inforaation included on this form. � Ci:�i.a�. _c,�i af, t�u�.am. �rw �ic f,.0u9 «�aw M wy c�+:j� tGau. ttii.� [�io Se y.[� �1'li�e3o�'a� c�ii'w. C�ieo �iai�. j+i.c 4to d�'va. lt6toAw lll=. 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