Monthly Statistics

Your Email Address:

Name of Nurse

Month/Year

Alert! Please verify Month/Year and change if you are not submitting for last month. (Data input format - MM/YYYY)

Faith Community

Additional Nurses

Monthly Number of Individual Contacts:

Contacts:

Total:

Male:

Female:

Ages:

0-12:

13-21:

22-50:

51-70:

Over 70:

Settings:

Church:

Home Visit:

Hospital:

Nursing Home:

Phone Call/Email:

Card Ministry:

New Baby Visit:

Clinic/Provider:

Other:

Referral:

Pastoral Staff:

Church Resources:

Healthcare Professional:

Physician:

Community Resources:

Other:

Total Time Worked This Month by Faith Community Nurses:

Meet with Pastor:

Health & Wellness Committee Meeting:

Screening:

Blood Pressure:

Lice:

Blood Sugar:

Cholesterol:

VOL:

Abnormal:

Referred:

Program and Activities Organized/Attended by Parish Nurse (Bulletin, Health Display, etc.):