The "Keep It With You" (KIWY) Personal Medical Information Form is intended to be a voluntary and temporary record that lists medical care and other health information for people who need care during disasters and similar situations.
- HypertensionInitial.doc (30.5 KB)
- asthmainitial.doc (38 KB)
- AdultAdolescentAssessmentForm.pdf (36.05 KB)
- NewPatientInformation.pdf (159.18 KB)
- MedicationRecord.pdf (262.37 KB)
Seven page document that provides a sample/template emergency preparedness plan.
- Emergency Preparedness.doc (230 KB)
The Workbook provides a process that can support state, local,and tribal planners as they advance in their efforts to reach all populations—and specifically, special populations—in day-today communication and during crisis or emergency situations.
The Workbook is divided into three primary sections, each representing a major stage in the process of communicating with special populations,and provides a baseline of research plus selected resources that should substantially reduce the work required of health departments to begin this process.
A few sample dental chart review forms/templates.
- Chart review sheets.doc (127 KB)
- dentalpeerreviewform.pdf (345.57 KB)
- PsychosocialAssessment.doc (68.5 KB)
- ChildAdolHistoryForm.doc (84 KB)
Adult personal history form designed for an individual to fill out prior to seeing a therapist.
- AdultHistoryForm.doc (91 KB)
- AdolescentSelfReport.doc (40.5 KB)
This is an integrated risk assessment form for STD, HIV, and hepatitis A, B, and C. The risk assessment form is designed to assess at-risk clients within your clinic and determine the services they should receive. This form is designed to be self-administered. Once the client has completed the form, it should then be reviewed by the clinic staff to determine the services the client is eligible to receive. In addition to screening, testing, and/or vaccine services, all clients should be offered appropriate counseling and educational materials tailored to their specific risks.
- STD_HIV_HepRiskTool.doc (43 KB)
MCN's Pesticide Clinical Guidelines and Pesticide Exposure Assessment Form assist in the recognition and management of acute pesticide exposures in primary care settings.
The pesticide guidelines were adapted from guidelines developed by Dr. Dennis H. Penzell, a former medical director of a Community and Migrant Health Center with experience in large-scale pesticide exposure incidents.
The Acute Pesticide Exposure Form was adapted from the data collection on an acute pesticide exposed patient tool developed by Matthew C. Keifer, MD, MPH, Director of the National Farm Medicine Center, appearing in the EPA's Recognition and Management of Pesticide Exposures, 6th Edition, EPA 2013.
These resources were developed with guidance from MCN's Environmental and Occupational Health Advisory Committee - a panel of healthcare professionals and researchers with expertise in pesticides and migrant health.
- PesticideClinicalGuidelines_2014Nov.pdf (395.73 KB)
- 2022-Pesticide-Exp-Assessment_ENG.pdf (316.56 KB)
- 2016-08-16 - Acute Pesticide Exposures Clinical Guidelines (Spanish).pdf (203.88 KB)
- 2022_Pesticide-Exp-Assessment_SPA.pdf (626.33 KB)
The following documents are a collection of the best resources available for taking a good occupational health history.
- WHACS.pdf (122.72 KB)
- WHACS in Spanish.doc (273.5 KB)
- I PREPARE.pdf (65.23 KB)
- PediatricHealthHistoryForm.pdf (59.81 KB)
- MCNConsensusQuestionsENG_SPA.pdf (41.59 KB)
Bilingual form to screen pregnant women for lead exposure. Developed by MCN.
Guidelines for health care providers from the Occupational Lead Poisoning Prevention Program, a program in the California Department of Public Health that helps employers, workers, and others prevent lead poisoning in workers.
- Lead_Worker_MedicalGuidelines_CA.pdf (313.4 KB)
Clinicial guidelines dealing with children and lead exposure. Special emphasis on working with migrant children.
This Guide provides information on Mexico's Immunization Schedule, including number of doses and recommended ages.
- biig-MX-CA.pdf (559.56 KB)
Use the link below to access MCN's Rapid Assessment Tool to help adolescent farmworkers identify agricultural tasks they perform in agriculture and facilitate clinician understanding about the health risks associated with it. Youth worker images are adapted and reproduced with permission from the National Children Center for Rural and Agricultural Health and Safety. Images copyrighted through Marshfield Clinic, Marshfield, Wisconsin.
If computers and internet access are unavailable where patient care is provided, the worker assessment sheet and clinician information grid are available in PDF.
- adol_fw_ rapidrisk_assess_clinician.pdf (3.94 MB)
- adol_rapidrisk_assess_board_2_0.pdf (7.03 MB)
Lifetime Card for adults. MCN, along with CHEC (Community Health Education Concepts), has developed patient-friendly, low literacy, bi-lingual immunization cards for you to use with your clients. The cards are 5x7, and can be printed from your clinic computers.
- Lifetime Immunization Record_1.pdf (694.02 KB)
- Lifetime Immunization Record-SP _1.pdf (661.04 KB)
http://www.informaworld.com/smpp/title~db=all~content=g924790533
The Journal of Agromedicine published this FREE special issue (Volume 15, Issue 3) that presents papers based upon the research and safety strategies presented at the "Be Safe, Be Profitable: Protecting Workers in Agriculture" conference held in January 2010 in Dallas, Texas. The conference was a joint meeting of the Agricultural Safety and Health Council of America (ASCHA) and the National Institute for Occupational Safety and Health (NIOSH). "It is our hope that this collection of editorials, panel presentations, plenary talks, and poster abstracts stimulates a new order of translational research, leading to effective research partnerships and improved health and safety outcomes," states Editor-in-Chief Steven Kirkhorn.
Do not miss the opportunity to read the results from this groundbreaking agricultural safety and health conference!