Congregation Information

Congregation Name:   Month(s)/Year:   Number of congregation members:

Nurse Information

Parish Nurse Name:   #of hours worked: Paid:   unpaid:   #of unpaid miles:

Nurse Activity Information

Blood Pressure Screenings:
Number of BP checks done:   Number of referrals for abnormal BP:    

Number of:
Bulletin board displays:   Newsletter/Bulletin Articles:   Presentations:  

Number of sessions lead:
Living Well with Chronic Conditions:   Matter of Balance/Stepping On:   Other:   Please indicate what other sessions you have lead:  

Number of Visits (Please indicate 'NP' if non parishioner):
At Chruch (don't count BP contacts):   Home:   Nursing Home/Assisted Living:   Hospital:   Telephone Contacts:   Care Transitions Coach Contacts:  

Number of Referrals made to:
Pastor:   MD/other health professional:   Community agency:   Other:  

Number of Interventions
Health teaching/counseling:   Crisis Intervention:   Bereavement:   Rites/Rituals:   Support:   Community liaison/Referral:   Correspondence:   Assessment:  

Other PN Activities (indicate the number of times you participate in the activity per month)
Facilitate/participate in groups:   List where you have participated in groups:  
Misc:   List all miscellaneous activities you have participated in:  

Outcomes and Improvements resulting from visits and other PN activities (indicate number of times) Enhanced quality of life:   Enhanced independent living (includes medical device obtained):   Disease risk reduction:   Injury prevention:   Hospital/ER avoidance:   Appropriate referral to hospital/ER referral:  

Specefic comments to clarify outcomes/parishioners remarks:

Thank you for your completing our survey.