DA Form 3761 Public Health Nursing Activities Report

DA Form 3761 - also known as the "Public Health Nursing Activities Report" - is a Military form issued and used by the United States Department of the Army.

The form - often mistakenly referred to as the DD form 3761 - was last revised on October 1, 2008. Download an up-to-date fillable PDF version of the DA 3761 below or request a copy through the chain of command.

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ACTIVITIES (check applicable box)
DATE
PUBLIC HEALTH NURSING ACTIVITIES REPORT
REQUIREMENT
CONTROL SYMBOL
For use of this form, see DA Pam 40-11;
DAILY
MONTHLY
MED-371
the proponent agency is OTSG.
WEEKLY
SECTION A - VISITS
TYPE OF VISIT
PERSONNEL CATEGORY
AGE GROUP
PROGRAM
CLASSIFICATION
n
o
p
l
m
q
r
s
t
a
b
c
d
e
f
g
h
i
j
k
1
MATERNAL AND CHILD
A. ANTEPARTUM
B. POSTPARTUM
C. NEWBORN
D. PREMATURE
2
CHILD ABUSE AND NEGLECT
3
SOCIOECON INVESTIGATION
4
HANDICAPPING CONDITIONS
5
HEALTH PROMOTION
6
INJURIES
7
MENTAL HEALTH
8
RETARDATION
9
DISEASE CONTROL
A. ARTHRITIS
B. CANCER
C. CARDIOVASCULAR
D. CHRONIC RESPIRATORY
E. DIABETES
F. OTHER CHRONIC
G. HEPATITIS
H. TB (Active & Reactivated)
I. TB (Surveillance)
J. VENEREAL
K. OTHER COMMUNICABLE
10
11
12
TOTAL VISITS
SECTION B - CLINICS, CLASSES
SECTION C - CASELOAD
NUMBER
PATIENTS
FAMILY RECORDS
SESSIONS
ATTENDANCE
a
b
c
*PT
NO.
*CT
PT
NO.
CT
CLINIC OR CLASS
26
TOTAL-BEGINNING OF REPORT
g
a
b
c
d
e
f
13
WELL BABY
27
OPENED
14
IMMUNIZATIONS
28
CLOSED
15
CHILD HEALTH
29
TOTAL-END OF REPORT
16
PRENATAL
SECTION D - MISCELLANEOUS
17
POSTPARTUM
ACTIVITIES
NUMBER
18
EXPECTANT PARENT
a
b
REFERRALS IN
19
DIABETIC
30
REFERRALS OUT
20
TB
31
TELEPHONE VISITS
21
32
UNABLE TO LOCATE VISITS
22
33
CONFERENCES ON BEHALF OF PATIENTS
23
34
CONFERENCES ON BEHALF OF PROGRAM
24
35
25
TOTAL CLINICS/CLASSES
36. OTHER PROGRAM ACTIVITIES (administration, staff development, meetings, etc.) (Continue on reverse)
NAME OF REPORTING INSTALLATION
NAME OF INDIVIDUAL PREPARING REPORT
* PT - PREVIOUS TOTAL
DA FORM 3761, OCT 2008
PREVIOUS EDITIONS ARE OBSOLETE
APD LC v2.00
* CT - CUMULATIVE TOTAL
ACTIVITIES (check applicable box)
DATE
PUBLIC HEALTH NURSING ACTIVITIES REPORT
REQUIREMENT
CONTROL SYMBOL
For use of this form, see DA Pam 40-11;
DAILY
MONTHLY
MED-371
the proponent agency is OTSG.
WEEKLY
SECTION A - VISITS
TYPE OF VISIT
PERSONNEL CATEGORY
AGE GROUP
PROGRAM
CLASSIFICATION
n
o
p
l
m
q
r
s
t
a
b
c
d
e
f
g
h
i
j
k
1
MATERNAL AND CHILD
A. ANTEPARTUM
B. POSTPARTUM
C. NEWBORN
D. PREMATURE
2
CHILD ABUSE AND NEGLECT
3
SOCIOECON INVESTIGATION
4
HANDICAPPING CONDITIONS
5
HEALTH PROMOTION
6
INJURIES
7
MENTAL HEALTH
8
RETARDATION
9
DISEASE CONTROL
A. ARTHRITIS
B. CANCER
C. CARDIOVASCULAR
D. CHRONIC RESPIRATORY
E. DIABETES
F. OTHER CHRONIC
G. HEPATITIS
H. TB (Active & Reactivated)
I. TB (Surveillance)
J. VENEREAL
K. OTHER COMMUNICABLE
10
11
12
TOTAL VISITS
SECTION B - CLINICS, CLASSES
SECTION C - CASELOAD
NUMBER
PATIENTS
FAMILY RECORDS
SESSIONS
ATTENDANCE
a
b
c
*PT
NO.
*CT
PT
NO.
CT
CLINIC OR CLASS
26
TOTAL-BEGINNING OF REPORT
g
a
b
c
d
e
f
13
WELL BABY
27
OPENED
14
IMMUNIZATIONS
28
CLOSED
15
CHILD HEALTH
29
TOTAL-END OF REPORT
16
PRENATAL
SECTION D - MISCELLANEOUS
17
POSTPARTUM
ACTIVITIES
NUMBER
18
EXPECTANT PARENT
a
b
REFERRALS IN
19
DIABETIC
30
REFERRALS OUT
20
TB
31
TELEPHONE VISITS
21
32
UNABLE TO LOCATE VISITS
22
33
CONFERENCES ON BEHALF OF PATIENTS
23
34
CONFERENCES ON BEHALF OF PROGRAM
24
35
25
TOTAL CLINICS/CLASSES
36. OTHER PROGRAM ACTIVITIES (administration, staff development, meetings, etc.) (Continue on reverse)
NAME OF REPORTING INSTALLATION
NAME OF INDIVIDUAL PREPARING REPORT
* PT - PREVIOUS TOTAL
DA FORM 3761, OCT 2008
PREVIOUS EDITIONS ARE OBSOLETE
APD LC v2.00
* CT - CUMULATIVE TOTAL

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