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APPENDIX A.

BLANKS AND RECORDS.

CHICAGO, ILL.

DEPARTMENT OF HEALTH, CITY OF CHICAGO.

School

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M. D. Nurse.

.; fair ........; fair

Health officer,
1. School phone..
2. Enrollment.
1. Sumber of rooms
4. Ventilation: Good..

; poor 5. Light: Good

; poor. 6. Average temperature. 7. Moisture.. 5. Sweeping: Moist...., dry....; vacuum. 9. Air intake: Ample....

......; inadequate. 10. Height of intake.. 11. Are seats adjustable to size of pupils? 12. Crinala, odor: Bad .. ; absent 13. Toilet facilities: Ample.....; inadequate. 14. Toilet paper provided: Yes : no. 15. Water supply: Lake. ...; well. ...; spring.. 16. Drinking utensils: Cup......; fountain. 17. Pencils: Individuals.... Pens: Common.. 18. Is register signed and kept as required? Yes...;

DO.... 19, Where is register kept?... 20. Vaccination records complete; where kept: Yes......

; no.

21. Regularity of health officer: Good fair....

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

i no. 23. Punctuality of health officer: Good..

fair .............; 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.

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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.)

191....

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

CHICAGO,

fArrival, Time of

(Departure,

Bebool,

Grade.

Number in grade.

Number examina

tions to date.

Number defective.

Recommended treat

ment.

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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.... Anæmia....

Other diseases of eye. Enlarged glands.

Hearing... Goitre....

Discharging ear Nervous diseases.

Nasal breathing. Cardiac diseases.

Palate.. Pulmonary diseases

Teeth... Skin diseases.

Hypertrophied tonsils.
Orthopedic.

Adenoids..
Mentality

Richitic type

Health Officer.

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DEPARTMENT OF HEALTH, CITY OF CHICAGO.

191..

DENTAL INSPECTOR'S DAILY REPORT.
School...

CHICAGO.
Total number examined.
Number found to have defective teeth.
Number needing immediate attentions
General condition of teeth found: Good.
Number of pupils applying for dispensary work.
Remarks..

; fair.

.; bad

D. D. $.

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DEPARTMENT OF HEALTH, CITY OF CHICAGO.

REPORT OF VACCINATIONS. (9-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 glyceripated 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..
Namber 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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