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APPENDIX A.

BLANKS AND RECORDS.

CHICAGO, ILL.

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M. D. Nurse..

fair...

21. Regularity of health officer: Good

fair.... ......; poor. 22. Is first school visited 9.15? Yes..

ino. 23. Punctuality of health officer: Good

; poor. 24. Regularity of nurse: Good..; fair...; poor. 25. Quality of health officer's work: Good. fair.

; poor. 26. Quantity of health officer's work: Good. fair....

; poor..... 27. Does principal, nurse, and health officer know

where register is? 28. Does health officer visit each school daily?. 29. Interest in work of health officer: Good... fair....

.; poor. 30. Interest of nurse in work: Good. fair..

.; poor.. 31. Does principal get prompt notice of new cases

and terminations? Yes.........; no..... 32. Is health officer inspecting parochial schools in

his territory?...... 33. Is health officer doing good work?.

M.D., Supervising Health Officer.

DEPARTMENT OF HEALTH, CITY OF CHICAGO.

Health offort,

...; fair.
.; fair

1. School phone.
2. Eurollment..
3 Scmber of rooms.
4. Ventilation: Good.

; poor š. Light: Good......

; poor. 6. Average temperature. 1. Moisture.. 1. Sweeping: Moist ....; dry....; vacuum. 9. Air intake: Ample.. ; inadequate. 10. Height of intake. 11. Are seats adjustable to size of pupils?. 12. Irinala, odor: Bad 11. Tolet facilities: Ample.. .; inadequate. 14. Toilet paper provided: Yes

......: no 15. Water supply: Lake....; well. ...; spring.. 18. Drinking utensils: Cup......; fountain. 17. Pencils: Individuals..... Pens: Common.. 18. Is register signed and kept as required? Yes...;

20.... 19. Where is register kept?...... 2). Vaccination records complete; where kept: Yes......

no..

...; absent

Date...

19.....

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DEPARTMENT OF HEALTH, CITY OF CHICAGO.

Address.....

Name...

PHYSICAL RECORD. Sex.. i age.

.; birthplace. Nationality of father.

; mother. Number of children in family.

history of measles. Diphtheria.... .....; pertussis.

...; pneumonia.

.; scarlet fever.. School....

Vaccinated?
Date first examination....

19.....
[O placed in square means absence of defects. X denotes defects.)

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2. Years in school..... 3. Revaccination... 4. Diseases during year.. 5. Date of physical examination. 6. Height. 7. Weight. 8. Nutrition. 9. Anemia 10. Enlarged glands. 11. Goitre.. 12. Nervous diseases. 13. Cardial disease 14. Pulmonary disease. 15. Skin disease.. 16. Delect orthopedic 17. Richitic type. 18. Defect of vision 19. Other diseases of eye. 20. Defect of hearing.. 21. Discharging ear.. 22. Defect of nasal breathing. 23. Defect of palate.. 24. Defect of teeth. 25. Hypertrophied tonsils. 26. Adenoids. 27. Mentality. 28. Conduct.. 29. Effort. 30. Proficiency. 31. Was treatment advised?.

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Number of vaccinations performed: Previous vaccination, .......; revaccination, .......; total,
Number physicals made, .

Number children found defective,
Number advised to seek treatment,

Number of cultures made,

Health Officer (Reverse side for exclusions.)

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191....

DIVISION OF CHILD HYGIENE-EXAMINER'S DAILY SCHOOL REPORT AND SUMMARY.

CHICAGO,

JArrival,
Time of

(Departure,

Bebool,

Grade.

Number in grade. Number examina

Number defective.

Recommended treat

ment.

tions to date.

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Number of physical examinations,
Number requiring treatment,

Nationality of those requiring treatment.
Native born,..

Foreign born, One or both parents foreign born

Defects found. Nutrition....

Vision.... Anemia.

Other diseases of eye Enlarged glands.

Hearing... Goitre.

Discharging ear. Nerrous diseases.

Nasal breathing. Cardiac diseases.

Palate.... Pulmonary diseases.

Teeth... Skin diseases.

Hypertrophied tonsils. Orthopedic.

Adenoids. Richitic type

Mentality

..., Health Officer.

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DEPARTMENT OF HEALTH, CITY OF CHICAGO.

REPORT OF VACCINATIONS. This monthly report of vaccination is to be made out and forwarded to the chief medical inspector at

the close of each month.)
Name of school
Report for the month of.

191..
Number of tubes of glycerinated vaccine received during the month.
Number of tubes of glycerinated vaccine used during the month.
Total number of primary vaccinations performed (successful)..
Total number of primary attempts at vaccination with failure.
Total number of revaccinations performed (successful)....
Total number of attempts at revaccination performed with failure.
Number of previous vaccinations examined and certificates issued therefor.
Kind of vaccine used and laboratory, numbers of same.

M.D.,
Medical Inspector.

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