Public Health Department Policy & Procedure Manual Example

Supplemental Fluoride Dosage Schedule


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Supplemental Fluoride Dosage Schedule


Concentration of Fluoride in Drinking Water (ppm)

Less then 0.3


Greater than 0.6

6 mo. To 3 years

3 to 6 years

6 to 16 years

0.25 mg F

0.50 mg F

1.0 mg F


0.25 mg F

0.50 mg F




* mg of fluoride/day – a 2.2 mg tablet of sodium fluoride contains 1 mg of fluoride.
Medication bottles are labeled appropriately and filled with 100 fluoride tablets of the correct dosage. Gloves will be worn and a towel will be placed on the desk when filling fluoride medication bottles. The 1 mg plastic vials can be filled 5/8’’ from the top (white). The 0.5 mg vials can be filled 7/8” from the top (pink). Bottles are capped tightly when stored and are kept in the locked cupboard.
Distributing Supplements:

When a family returns for supplements, assure the appropriate dosage is being distributed. Review the instruction form and reorder information. Record on the client’s card the date, dose, and number of supplements picked up.


POLICY TITLE: Fluoride Varnish Program



AUTHORIZED BY: Heidi Stewart, BSN, Health Officer / Director
The goal of the fluoride varnish program is to reduce the proportion of children who have dental caries experience in the primary and permanent teeth. This is one primary prevention component of the local health department’s oral health program.

  1. The Pepin County Health Department Varnish Program will serve infants and children with signed parental/legal custodian/guardian consent that will represent an on-going agreement between the two parties.

  2. The administration of the fluoride varnish program is the responsibility of Pepin County Health Department under the direction of the Pepin County Health Department Director/Health Officer or his/her designee and the medical advisor.

  3. Pepin County Health Department authorized registered nurses may apply fluoride varnishes for Pepin County Health Department. Registered nurse practices consistent with Chapter 441, Wisconsin Statutes, and HFS 139 if applicable.

  4. It is the responsibility of Pepin County Health Department Designee, to assess the need for, plan, implement, and evaluate the fluoride varnish application program.

  5. The Agency Director/Health Officer will assign support staff as necessary.



  1. The Pepin County Health Department will serve high risk infants and toddlers (under the age of six) during well baby examinations or during other health department sponsored events such as WIC Clinics, Healthchecks, Head Start screening, or well-child screening.

  2. Populations believed to be at increased risk for dental caries are those with low socioeconomic status or low levels of parental education, those who do not seek regular dental care, and those without dental insurance or access to dental services. Individual factors that possibly increase risk include active dental caries; a history of high caries experience in older siblings or caregivers; root surfaces exposed by gingival recession; high levels of infection with cariogenic bacteria; impaired ability to maintain oral hygiene; malformed enamel or dentin; reduced salivary flow because of medications; radiation treatment, or disease; low salivary buffering capacity (i.e., decreased ability of saliva to neutralize acids); and the wearing of space maintainers, orthodontic appliances, or dental prostheses. Risk can increase if any of these factors are combined with dietary practices conducive to dental caries (i.e., frequent consumption of refined carbohydrates). Risk decreases with adequate exposure to fluoride. (CDC, MMWR, 2001)


1. Record Keeping:

A signed copy of parent/legal custodian/guardian informed consent, medical history and screening form must be kept in the individual’s health record.

Name, date, birth date, grade, special health care needs status, Medicaid/BadgerCare status.

Using the medical history, prior to varnish placement, a caries risk assessment and oral screening is conducted by the registered nurse.

  1. Caries experience, untreated caries, early childhood caries or presence of sealants, treatment urgency (urgent, early or no treatment needs)

  2. Indication for fluoride varnish application

  3. Application dates and provider initials

  4. Name of licensed individual conducting screening
  5. Comments and indication of referral

D. The need for fluoride varnish placement will be determined consistent with United States Centers for Disease Control and Prevention, 2001, Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States, MMWR.

E. All applicable federal and state occupational safety and health records will be maintained at the Pepin County Health Department.

All applicable confidentiality requirements will be met.

2. Fluoride Varnish Placement Standards

  1. DHFS Publications: Integrating Preventive Oral Health Measures Into Healthcare Practice: Training Program for Healthcare Settings or Healthy Teeth for Mom and Me

3. Occupational Safety and Health

  1. The Pepin County Health Department follows CDC Guidelines For Recommended Infection Control Practices in Dentistry

4. Adverse Event Protocol

  1. Edematous swellings have been reported in rare instances, especially after application to extensive surfaces. Dyspnea, although extremely rare, has occurred in asthmatic people. Nausea has been reported when extensive applications have been made to patients with sensitive stomachs.

  2. If required, varnish is easily removed with thorough tooth brushing and rinsing.

  1. Safety temporarily discolored, as fluoride varnish has an orange-brown tint.

  2. Explain the discoloration will be brushed off the following day.

6. Contraindications

A. Avoid applying varnish on large open carious lesions. Referral to a licensed dentist is indicated in this instance.

B. Gingival stomatitis

C. Ulcerative gingivitis

D. Intra oral inflammation

E. Known sensitivity to colophony or colophonium or other product ingredients which include: Ethyl Alcohol Anhydrous USP 38.58%, Shellac powder 16.92%, Rosin USP 29.61%, Copal, Sodium Fluoride 4.23%, Sodium Saccharin USP 0.04%, Flavorings, Cetostearyl Alcohol

  1. Fluoride Varnish Materials: USDA approved Fluoride Varnish, 2x2 gauze, applicator, disposable mouth mirror, toothbrush, lap barrier and a cold glass of water.Precautions

  1. Remind the parent/legal custodian/guardian to give the child something to eat or drink before their appointment to receive fluoride varnish application.

  1. Advise the parent/legal custodian/guardian that the child’s teeth may become

Schedule and Dosages

1. Apply fluoride varnish no less than two times per year and up to three times per year for a child with high risk, by a registered nurse. (See target populations.)

The goal is to apply a thin layer of 5% sodium fluoride varnish to all surfaces of erupted primary or permanent teeth on eligible children participating in the Women, Infants and Children (WIC), HealthCheck, Head Start.

1. Consistent with the DHFS Integrating Preventive Oral Health Measures Into HealthcarePractice: Training Program for Healthcare Settings or Healthy Teeth for Mom and Me

  1. Oral health screening and risk assessment will initially be conducted by the Pepin County Health Department registered nurse.

  2. Obtain medical history and consent.

  3. Do not apply varnish if there is a known allergy to colophony components

  4. Conduct risk assessment of the individual

  1. Caries experience

  2. Dental care utilization pattern

  3. Use of preventive services

  4. Medical history (e.g. xerostomia)

  1. Do not apply varnish to surfaces with overt (frank) tooth decay or gingival stomatitis

  1. Based on assessment, determine application schedule and prepare for varnish

application in accordance with the dosage schedule:

  1. Verify written parent/legal custodian/guardian consent.

  2. Explain procedure to parent/legal custodian/guardian.


1. Apply fluoride varnish

  1. Gather supplies: varnish, 2x2 gauze, applicator, container to hold varnish, disposable mouth mirror, toothbrush, dental bib or lap barrier and cold glass of water.

  2. Don personal protective equipment: protective. Mix varnish.

  3. The parent may hold the child or use a dental chair.

  4. Lift the upper lip and screen for contraindications, conduct oral screening and provide instruction to parent/legal custodian/guardian of infants and toddlers.

  5. Dry the upper front teeth with gauze.

  6. Apply or “paint” the varnish on the front and back of the upper front teeth.

  7. Dry the remaining teeth.

  8. Apply the varnish on the remaining teeth including the occlusal (biting) surfaces.

  9. Sit the child up and offer glass of water.

2. Follow-up.

A. Instruct the guardian to have the child refrain from eating or drinking for 4 hours. If the child must eat, offer only soft food and water.

B. Instruct the guardian not to brush until the following morning. Inform the guardian that the teeth may remain an amber color. This will come off when the teeth are brushed.

  1. Review child’s age appropriate anticipatory guidance schedule with parent/legal custodian/guardian.

  2. Complete referrals.

Make plan with parent for subsequent visit. Ideally, fluoride varnishes will be placed at an initial appointment with two additional applications within a one-year period (a total of three applications).

Inform parent/legal custodian/ guardian of procedures, provide post application instructions and communicate referral status.


  • Balistreri, Thomas J., Assistant Attorney General, December 9, 2004 Letter to Steven M. Gloe, General Legal Counsel, Department of Regulation and Licensing.

  • Casamassimo P, ed. 1996. Bright Futures in Practice: Oral Health. Arlington, VA: National center for Education in Maternal Health and Child Health.

  • University of Iowa Center for Leadership Training in Pediatric Dentistry, Oral Management of Pediatric Patients for Non-Dental Professionals,, Retrieved 3/11/05.

  • United States Centers for Disease Control and Prevention, 2001, Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States, Morbidity and Mortality Weekly Report. 50. RR-14.

  • United States Centers for Disease Control and Prevention, 2003. Guidelines for Recommended Infection Control Practices in Dentistry, M MWR, December 19, 2003:52(RR- 17).

  • United States Department of Health and Human Services (DHHS). Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. DHHS, National Institute of Dental Craniofacial Research, National Institutes of Health, 2000.

  • Wisconsin Statutes and Administrative Code Relating to the Practice of Dentistry and Dental Hygiene.

  • Wisconsin Statutes and Administrative Code Relating to the Practice of Nursing

  • Balistreri, Thomas J., Assistant Attorney General, December 9, 2004 Letter to Steven M. Gloe, General Legal Counsel, Department of Regulation and Licensing.

  • Wisconsin Administrative Code, Chapter HFS 139, Qualifications of Public Health Professionals Employed by Local Health Departments.

  • Wisconsin Statutes and Administrative Code Relating to the Practice of Dentistry and Dental Hygiene.

  • Wisconsin Statutes and Administrative Code Relating to the Practice of Nursing.

PROCEDURE TITLE: Urine Screening: Chlamydia and Gonorrhea



AUTHORIZED BY: Heidi Stewart, BSN, Health Officer / Director
Asymptomatic women and men at risk for sexually transmitted infection will be provided with screening tests so that early infection can be detected and treated promptly before more severe damage is allowed to develop. Additionally, since a majority of sexually transmitted diseases are transmitted by asymptomatic persons, detection and treatment of asymptomatic carriers is a mainstay of sexually transmitted disease control.

The Pepin County Reproductive Health Program will provide assessment, testing, treatment, education and partner follow-up services to men and women to prevent the transmission of

sexually transmitted diseases. Screening will be provided for individuals at risk of STDs, including asymptomatic individuals, contacts of STD patients, and individuals with multiple sex partners.

1. Screening may be provided for all reproductive health and family planning clients. Clients who present with sexually transmitted infection symptoms will be referred to their primary physician or the program nurse practitioner.

2. The Chlamydia-Gonorrhea Combination Nucleic Acid Amplification Test (NAAT) kit, as supplied by the Wisconsin State Lab of Hygiene, will be used.

3. Male and female patients should not urinate for at least one hour prior to the urine specimen collection. Mucus and exudates should be removed prior to collecting swab specimens.

4. Collect 15-20 mL of first void urine (NOT mid-stream) into a sterile plastic preservative-free container.

5. Aseptically transfer up to 10 mL of urine to the “DNA Protect” preservative tube, to the red fill line.

6. Label the transport container with the client identification information and the date collected.

7. Swab specimens and urine specimens placed in “GENELOCK” transport kits may be transported to the laboratory at ambient temperatures. Use pressure-resistant bags as inner packaging for liquid (urine and swab) specimens. Avoid temperature extremes. Urine specimens in preservative tube as described may be stored and transported at ambient temperatures for up to 6 days. Do not freeze urine or swab specimens. Specimens must be tested within six days of collection.

8. The CDD Requisition Form A must be completed to include the minimum information. Laboratory regulations require the following minimum information to be provided on the requisition form for a specimen to be accepted for testing: Patient name or unique identifier; date and time of collection, patient date of birth and sex, specimen type/site of collection, test request(s), clinician name and UPIN, and address for reporting results. Please be certain that name/identifier on the form matches that on the specimen label.

POLICY TITLE: Completing a Urinalysis



AUTHORIZED BY: Heidi Stewart, BSN, Health Officer / Director
To assure consistent and appropriate care is provided to family planning clients.
The Pepin County Health Department completes the urinalysis (UA) for family planning clients.


  1. The UA can be done to new or established clients giving history to possible UTI symptoms.

  2. After completing appropriate paperwork (see above listed policies/procedures), explain the UA to the client.

  3. Show the client to the bathroom and have her urinate in a urine specimen cup. Have her leave the cup in the bathroom on small table.

  4. Remove one test strip from the DiaScreen bottle, and replace the cap immediately.

  5. Apply gloves.

  6. Test the urine immediately by immersing a reagent test strip into urine.

  7. When removing the test strip from the urine cup, run the edge of the strip against the rim of the urine container to remove excess urine.

  8. Hold the strip horizontally, close to the color strips on the outside of the test strip bottle.

  9. Read the test results at the appropriate time interval, as marked on the bottle. All tests are read at 60 seconds, except Leukocytes, which is read at 120 seconds.

  10. Document the results on the Exam Form.

  11. Discard excess urine from the urine cup into the toilet.
  12. Recap the urine cup and throw it in the garbage.

  13. Remove gloves and wash hands.



PROCEDURE TITLE: Family Planning Only Services Program



AUTHORIZED BY: Heidi Stewart, BSN, Health Officer / Director
To offer the Family Planning Only Services benefit to eligible residents of Pepin County.

The Pepin County Health Department offers family planning services to residents of Pepin County. As part of this program, the Wisconsin Medical Assistance Family Planning Only Services Program has been implemented to assist the State of Wisconsin in meeting its goal of reducing the number of unintended pregnancies. This program provides limited benefits for family planning services and supplies.

Non-Financial Eligibility Requirements:

In order to qualify for the Family Planning Only Services Program, the person must (all requirements must be met):

  • Be age 15 or older;

  • Be a Wisconsin resident (is 30 days);

  • Be a United States citizen;

  • Not be enrolled in full coverage Medical Assistance;

  • Provide a Social Security Number.

Note: If the individual does not know their social security number, a pseudo-number can be obtained by calling provider services at 800-947-9627 (608-221-5720).
Financial Eligibility Requirements:

In addition to the non-financial requirements, the client must also be at or below 300% of the federal poverty level for their group size.

Income included in determining eligibility:

  • Wages and salary

  • Child support received

  • Unemployment compensation

  • Tribal payments

Income not included in determining eligibility:

  • Social Security Income

  • Student loans or grants

  • Foster Care payments

  • W-2 payments

  • Income of full-time students

  • Income of part time students working under 30 hours per week

  • If the applicant is a minor, do not count the parents’ income.

  • Allowable deductions from income: child support paid out

Note: When determining group size, count the applicant, their spouse (live-in boyfriends do not count), natural or adoptive children, and fetuses of any group member. For applicants who are minors, the group size will be 1 plus fetus(es) and/or children of the minor (parents of minors are not counted).

All new family planning patients will be screened for Family Planning Only Services eligibility at their first visit. All current family planning patients will be screened for Family Planning Only Services eligibility at their next regularly scheduled office visit.
Temporary Enrollment (TE):

  • Local health department family planning staff can assist patients with completion of the temporary enrollment application

  • The same staff can make a preliminary determination of eligibility for the Family Planning Only Services Program and provide coverage for services immediately.

  • See attached Temporary Enrollment for the Family Planning Only Services Application Instructions for Instructions.
  • After assisting the patient with completion of the application and determination that the patient is temporarily eligible for the program, the patient can receive covered family planning services and supplies.

  • The TE application can be faxed to (608)221-2742. This fax number is devoted to Family Planning Only Services Temporary Enrollment applications.

  • Eligibility extends from the date the client is found eligible until the end of the next month.

  • The client must then apply for full Medical Assistance or the Family Planning Only Services to continue eligibility for covered services and supplies.

  • The health department staff will assist all clients determined to be temporarily eligible for the Family Planning Only Services in completion of the full family planning waiver application.

  • Temporary enrollment can only be received one time in a 12-month period.

  • Once health department staff has determined that a client is temporarily eligible for family planning services, medical assistance will be billed for services provided. The public health nurse will complete a Pepin County Health Department Family Planning billing form for each clinic visit for eligible clients (see attached).

Application Process:

  • Those clients’ determined to be temporarily eligible for the Family Planning Only Services program must also complete the 2-page application to continue eligibility beyond the first two months by phone, online at Access, or the 2-page paper application.

  • Anyone can assist the client with this application, but in order to assure the completion and submission of the form and avoid providing services to a client whose TE has expired and is no longer covered, the family planning staff will assist temporarily eligible women in completion of the 2-page form the same day they are determined to be temporarily eligible.
  • See the attached Wisconsin Family Medicaid, Badgercare, and Family Planning Only Services Application and Review and Instructions attached for instructions in completing the application.

  • Inform client need to document citizenship, identity, and income (if applicable). See WI MA Fact Sheet on Citizenship and Identity Documentation.

  • Once the application is complete, family planning staff will fax the client’s verification to the enrollment services center (if the client has the verification with them) or instruct the client to mail the verification information to the enrollment services center. Enrollment services must receive any needed verification to process the application.

  • Final eligibility is determined by the State Medicaid Enrollment Services Center.

  • The patient will receive a notice of the decision and a Forward Card after the information is entered by the Enrollment Services and they are determined to be eligible for the program.

  • All mailing information can be sent to the health department instead of the individual’s home if she prefers. This must be indicated on the application.

Covered Services:

See attachment for a list of services that are covered by the Family Planning Only Services Program. There is no co-payment for covered services or supplies.


Some minors may be concerned that applying for this program may result in mail being sent to their home. Both Temporary Enrollment and the regular Medical Assistance applications have a space where they can write that they wish for all correspondence to be sent to the local health department. Parents of minors will not be contacted for any reason. All clients are notified in writing of their privacy and confidentiality rights.

Family Planning Only Services Program and the Wisconsin Well Woman Program (WWWP)

Please refer women between the ages of 35-44 who need contraceptive management and are not currently enrolled in the WWWP to the Family Planning Only Services Program. The FPOS Program covers the CBE, Pap, and pelvic exam. However, because the FPOS Program does not provide coverage for mammography, we will offer limited mammography services to women aged 35-44 enrolled in the FPOS Program who are in need of a mammogram as a result of an abnormal CBE. However, the client must suspend their active involvement in the FPOS Program and contact their local coordinating agency for WWWP enrollment and referral for mammography services. For more information on the FPOS Program please see:
Women eligible for both programs should consider first applying for the WWWP to receive cervical and breast cancer screening. If these screenings are normal, she could then apply for the Family Planning Only Services Program for contraceptive uses.



POLICY TITLE: Hemoglobin Testing



AUTHORIZED BY: Heidi Stewart, BSN, Health Officer / Director
To assure that completion of the Hgb testing is done per provider discretion. To assure consistent and appropriate care is provided to family planning clients.
The Pepin County Health Department completes the hemoglobin (Hgb) test for family planning clients.


  1. The Hgb is done at the health department for family planning patients using the reproductive health grant with a voucher for family planning services, and for patients going to Castleberg Clinic under the Family Planning Waiver program. Hemoglobin testing will be done at clinicians discretion based on discussion with client and reviewing medical history.

  2. After completing the appropriate paperwork (see above listed policies/procedures), explain the Hgb test to the patient.

  3. Prior to procedure, the Code Key that matches the test cards must be inserted in the meter. Test Cards expire 90 days after the bottle is opened.
  4. Seat the patient comfortably and ensure that the patient’s hand is warm so the blood circulates freely before sampling. The patient’s fingers should be straight, but relaxed to avoid the stasis effect, which occurs when fingers are bent.

  5. Firmly insert the Test Card that matches the Code number. When the display shows HGB and a flashing drop symbol, apply the sample.

  6. Wearing gloves, clean the tip of the middle or ring finger with alcohol and allow it to dry.

  7. Lightly press the finger from the top knuckle towards the tip. This stimulates the flow of blood towards the sampling area.

  8. Using a retractable lancet, prick the side of the selected finger, towards the tip. Place the used lancet in a red biohazard sharps container.

  9. Using a dry absorbent pad, wipe away the first drop of blood.

  10. Position the next large hanging drop of blood directly over the center of the test card and carefully touch it to the center hole. The countdown will automatically begin. If preferred, transfer pipettes may be used.

  11. Do not touch or reposition the test card while the meter is reading. Results will be displayed in the window and the meter will automatically turn off after two minutes. Discard test card in red biohazard sharps container.

  12. Remove gloves and wash hands.

  13. Document the result on the back of the pink Initial History and Physical form or the green Annual History and Physical form.

  14. Remember to give the patient the pink or green form, along with a voucher, to take to the exam with her.

Controls: Controls should be run with each new box of Test Cards and at the beginning of each month.

  1. Keep controls in the refrigerator. Bring to room temperature for 20 minutes, roll in palm, and invert but do not shake, to suspend all particles.

  2. Place one drop on center of Test Card. Expected Range is specific to the lot number and is on the Control insert.
  3. Controls are good for 12-18 months unopened, and 60 days once opened.

  4. If Control is not within range, pull up the Test Card platform and remove.

Clean the optic window with a damp q-tip, followed by a dry q-tip. Replace the platform and repeat Control test.


PROCEDURE TITLE: Emergency Contraception Response Line Lock Box



AUTHORIZED BY: Heidi Stewart, BSN, Health Officer / Director
To make Plan B (emergency contraceptive pills) widely and readily available to Family Planning Health Services clients 24 hours a day, 7 days a week.
Pepin County Health Department will provide a lockbox stocked with one emergency contraception kit for participants in the Family Planning Health Services Program.

Set the code for the lock box (don’t forget to write it down!). Stock the box with one emergency contraception response line kit. Each kit should include the following: Plan B, instructions on

how to use Plan B, 2 response line wallet cards, condoms (10 male latex condoms, 3 non-latex female condom), a brochure titled, “Get it Before You Need It”. When the kit has been used,

staff from the Emergency Contraception Response Line will email the designated contact at the Pepin County Health Department. After use, restock the lock box and change the code. Write down the code used on the lockbox tracking form. Email the new lock box code to Frances at

There is no preset combination on the TouchPointLock. Select your own combination. For best results, select between four and seven numbers in your combination. Each number can only be used one at a time. Do not use a number combination that can be easily guessed.

Setting the combination:

NOTE: Open knob must be in LOCKED position before the code can be changed!

  1. Press down on clear. Then turn the open lever to open the cabinet. Remove the plastic card from the back of the lock by lifting from the center of the edges.

  2. Remove the plastic card from the back of the lock by lifting from the center of the edges.

You will see ten numbered buttons with arrows. These numbers correspond to the

numbered buttons on the front of the lock. All arrows on the screws point up because there is no preset combination.

  1. Use the screwdriver tip on the plastic card or a small screwdriver to rotate the arrows. For each number in your combination, apply light pressure and rotate a half turn so that the arrows point down and snap up.

  2. Check to make sure that the arrow of any number that is not in the combination is pointing up.

Caution: Arrows must point either up or down. An arrow pointing up is not a number in the combination. An arrow pointing down is a number in the combination. If any arrow is pointing left, right or has not snapped up, the combination will not work. Test the combination before locking the cabinet.

  1. Replace the plastic card on the back of the lock.

Testing your combination:

1. Make sure the OPEN lever is in home position. If not, turn OPEN lever counterclockwise until it is in the home position. On the front of the lock, push only the numbered buttons on your combination. If a mistake is made, pull down on the CLEAR button and re-enter the combination.

  1. Turn the OPEN lever clockwise to open. If the combination is set correctly, the OPEN lever will cam and turn fully at the same time. If not, pull down on the CLEAR button and reset combination.

Opening and using the lockbox:

  1. Push in the buttons that correspond to the combination you have set. Buttons may be

pushed in any order.

  1. Turn the lever clockwise to unlock the box. If you have entered an incorrect combination, you can return the buttons to the original setting by sliding down the clear button.

  2. When you turn the lever, the combination will clear.

  3. To relock the lock, close the cabinet or enclosure and turn the OPEN lever counter-clockwise. When you release the lever, the cabinet will be locked.

REFERENCES/LEGAL AUTHORITY: Family Planning Health Services

PROCEDURE TITLE: Packaging and Transport of Laboratory Specimens



AUTHORIZED BY: Heidi Stewart, BSN, Health Officer / Director
To offer proper packaging and transport of laboratory specimens
The Pepin County Health Department will comply with directions from the WSLH for the packaging and transport of laboratory specimens.

1. For screw on cap vials – make sure the lids are on TIGHT before shipping. Because of the “o” ring features of the vials no need to tape or parafilm. The WSLH is specifically requesting

that you do not tape or parafilm the lids.

2. Make sure to use the appropriate biohazard bag and that there is absorbent material in each bag. The bags are absorbent material and available through the WSLH. Do NOT tape or otherwise attaché the absorbent material to the tubes. Liquid specimens need the special pressure biohazard bags. However, liquid base pap specimens and cervical biopsy specimens are exempt from the pressure bag requirement. When using the “pressure bag” for urine and cervical Chlamydia specimens it is requested that you insert more than one specimen per pressure bag. Make sure you securely close the biohazard bag. Lab requisitions go in the separate pouch on the outside of the biohazard bag.

3. Ship your specimens in Styrofoam containers supplied by the WSLH. All of the shipping containers from the WSLH meet the transport requirements.

4. Your return shipping label must include: agency name, agency address, agency phone number, and name of agency contact person.

5. Use the shipping label provided by WSLH. - Be sure to affix the UN3373 label supplied by the WSLH on the outside of the Styrofoam container.

6. Make sure your specimen labels have 2 identifiers (ie. name and date of birth)

7. Make sure the names of the specimen label and on the lab requisition are identical matches. If you are sending information for insurance billing then all 3 must match. It would be preferred that the specimen labels be printed labels if at all possible.

8. Tape shut, postage, and mail.


  • Wisconsin State Laboratory of Hygiene




AUTHORIZED BY: Heidi Stewart, BSN, Health Officer / Director

  1. To assure early detection of, and effective response to, sexually transmitted infections.

  2. To reduce incidence of sexually transmitted infections.

  3. To provide epidemiological follow-up on all reportable sexually transmitted infections.

  4. To provide education on disease prevention to individuals and the community.

  5. To observe and report trends in sexually transmitted infection rates

In collaboration with the Communicable Disease Section of the Wisconsin Division of Public Health, Pepin County Health Department executes the requirements described in Chapter 252 Wisconsin Statutes regarding the reporting, surveillance, and control of communicable diseases, including sexually transmitted infections. These responsibilities are accomplished through the cooperative efforts of hospital infection control personnel, health care providers, local health departments, and the Wisconsin State Laboratory of Hygiene.


Pepin County Health Department encompasses both passive disease surveillance (from provider reports) and active disease surveillance (initiating contact to search for possible cases). Pepin County Health Department maintains a surveillance system that is compatible with the statewide system, including:

  • Maintaining a supply of current communicable disease report forms (DOH 44151/4243);

  • Supporting training of staff to accurately and efficiently use the Wisconsin Electronic Disease Surveillance System (WEDSS).

  • Receiving, evaluating, and transmitting completed reports to the state epidemiologist.

  • Investigating each sexually transmitted infection reported to gather epidemiologic and laboratory data for local, state, and national surveillance.

  • Conducting a detailed follow-up as noted in the Control of Communicable Diseases Manual (current edition) to prevent future cases, identify contacts, and prevent further transmission.

  • Consulting with the state epidemiologist or other Division of Public Health staff whenever any unusual circumstances occur or to help answer questions.

  • Implementing control measures for specific diseases consistent with measures recommended by the state epidemiologist.

  1. Upon diagnosis of a sexually transmitted infection, the clinic/lab/provider will complete the DOH 4243 and send it to Pepin County Health Department or complete the information in WEDSS and submit it electronically to the Pepin County Health Department.

  2. The DOH 4243 will be given to the Health Officer for review. Case follow-up will be delegated to a public health nurse (PHN). If received electronically, the local WEDSS system administrator will assign the case to a PHN.

  3. If the lab/clinic/provider calls with a report and does not send a DOH 4243, health department staff will complete the form and enter the data into WEDSS.
  4. Using the EPINET and Control of Communicable Diseases Manual, the nurse will read the information available about the particular disease and complete any additional required forms. If additional forms are required, they will be found in the EPINET.

  5. After gathering this information, the nurse will call the MD or facility that performed the testing in order to obtain treatment information and pregnancy status. Any information still needed to complete required forms will be obtained at this time.

  6. The nurse will contact the individual as soon as possible following receipt of the report of the sexually transmitted infection. The individual will be instructed regarding treatment, prevention and the potential source of the infection. Any questions the individual may have will be addressed. It is often helpful to send the client a copy of the Wisconsin DHS communicable disease fact sheet for the specific disease.

  7. If the nurse is unable to reach the client by phone, contact will be initiated via mail. If the client does not respond after three written letters, all paperwork will be submitted to the Division of Public Health Communicable Disease section and the case will be closed. Several attempts will also be made via phone calls at different times of the day.

  8. If unable to submit data electronically via the WEDSS Reporter, completed paperwork will be submitted to (“CONFIDENTIAL” will be typed on the envelope):

    1. Wisconsin Division of Public Health

    2. Communicable Disease Section

    3. 1 West Wilson Street, Room 318

    4. Madison, WI 53702

    5. Or, the report can be faxed to 1-800-269-9300

  9. If Pepin County Health Department receives a higher than usual number of reports for a given disease, enhanced surveillance will be initiated to determine if the cases are related.
  • Reports, examinations, and all records concerning sexually transmitted infections are confidential and not open to public inspection (Wisconsin Statute 143.07).

  • No contacts will be provided any information regarding the source case.

  • Reporting requirements for minors are covered under the child sexual abuse reporting statutes. Minors who have been interviewed will not be referred to social services as sexual assault cases without first consulting with the referring clinician.

  • Keep in mind that the child may have been the victim of a crime. If a crime against a minor is suspected, this will be reported to the Pepin County Sheriff’s Department immediately.

  • In accordance with Wisconsin Statute 252.05(11), any violation of communicable disease reporting by physicians or other health care providers will be reported to the Pepin County District Attorney’s Office.

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