Êîìó____________________________________________________________________
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ÄÎÍÅÑÅÍÈÅ

î ðåçóëüòàòàõ ñàíèòàðíî-ýïèäåìèîëîãè÷åñêîé ðàçâåäêè

1.Äàòà_________ ,
âðåìÿ_________ñèëàìè___________________________________________

ïðîâåäåíà
ÑÝÐ__________________________________________________________________

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________________________________(ÓÊÀÇÀÒÜ Ð-ÍÛ, ÌÀÐØÐÓÒÛ, ÍÀÑÅËÅÍÍÛÅ
ÏÓÍÊÒÛ, Ð-ÍÛ ÒÏÓ,ÊÏ ÈÒÄ.)______ 
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2.Ñàíèòàðíî-ýïèäåìè÷åñêîå ñîñòîÿíèå(ÄÀÒÜ ÎÁÙÓÞ ÎÖÅÍÊÓ ÑÀÍ-ÝÏÈÄ.
ÑÎÑÒÎßÍÈß Ð-ÍÀ, ÎÁÚ-ÅÊ-

ÒÎÂ)
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ïî(ÓÊÀÇÀÒÜ ÏÎ ÊÀÊÈÌ ÍÎÇÎËÎÃÈ×ÅÑÊÈÌ
ÔÎÐÌÀÌ)_________________________________________

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3.(ÍÀÑÅËÅÍÍÛÅ ÏÓÍÊÒÛ, ÎÁÚÅÊÒÛ, ÑÐÅÄÈ ÊÎÒÎÐÛÕ ÂÛßÂËÅÍÛ Î×ÀÃÈ 
ÈÍÔÅÊÖÈÎÍÍÛÕ ÇÀÁÎËÅÂÀÍÈÉ)__

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4.Â
(Ð-ÍÛ)__________________________________________________________________
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âûÿâëåíû ýïèçîîòèè_(ÓÊÀÇÀÒÜ ÍÎÇÎËÎÃÈ×ÅÑÊÈÅ
ÔÎÐÌÛ)_________________________________

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ñðåäè(ÑÅËÜÑÊÎÕÎÇßÉÑÒÂÅÍÍÛÕ, ÄÎÌÀØÍÈÕ ÆÈÂÎÒÍÛÕ, ÄÈÊÈÕ
ÃÐÛÇÓÍÎÂ)______________________

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5.Ñàíèòàðíî-ãèãèåíè÷åñêîå ñîñòîÿíèå(ÒÅÐÐÈÒÎÐÈ, ÍÀÑÅËÅÍÍÛÕ
ÏÓÍÊÒÎÂ)__________________

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(ÓÄÎÂËÅÒÂÎÐÈÒÅËÜÍÎÅ ÈËÈ ÍÅÓÄÎÂËÅÒÂÎÐÈÒÅËÜÍÎÅ) ïî
ïðèçíàêàì__________________________

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6.Îáñëåäîâàíû âîäîèñòî÷íèêè(ÍÀÑÅËÅÍÍÛÅ ÏÓÍÊÒÛ, ÕÀÐÀÊÒÅÐ ÂÎÄÎÑÍÀÁÆÅÍÈß,
ÄÅÁÈÒ ÇÀÊÐÛÒÛÕ ÂÎÄÎÈÑÒÎ×ÍÈÊÎÂ, ÄÀÒÜ ÇÀÊËÞ×ÅÍÈÅÎ ÏÐÈÃÎÄÍÎÑÒÈ
ÂÎÄÛ)__________________________________

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7. (ÍÀÑÅËÅÍÍÛÅ
ÏÓÍÊÒÛ)___________________________________________________________
èìåþòñÿ (ÁÀÍÈ, ÑÀÍ. ÏÐÎÏÓÑÊÍÈÊÈ,Ñ ÏÐÎÏÓÑÊÍÎÉ
ÑÏÎÑÎÁÍÎÑÒÜÞ)___________________________

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(ÑÝÓ, ËÅ×ÅÁÍÛÅ Ó×ÐÅÆÄÅÍÈß, ÈÕ ÊÎÅ×ÍÀß ÅÌÊÎÑÒÜ,  Ò.× ÈÍÔÅÊÖÈÎÍÍÛÅ
ÊÎÉÊÈ)_________________

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8. (ÍÀÑÅËÅÍÍÛÅ ÏÓÍÊÒÛ)
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____________________________________________________èìåþòñÿ çàïàñû
ìåäèöèíñêîãî èìóùåñòâà (ÍÀÈÌÅÍÎÂÀÍÈÅ,
ÊÎËÈ×ÅÑÒÂÎ)______________________________________________

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9.Â(ÐÀÉÎÍÛ ÐÀÑÏ-ß, ÍÀÑÅËÅÍÍÛÅ ÏÓÍÊÒÛ)
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îòîáðàíû ïðîáû äëÿ ñïåöèôè÷åñêîé èíäèêàöèè áàê. ñðåäñòâ(ÏÐÈ ÍÀËÈ×ÈÈ
ÔÀÊÒÎÂ ÏÐÈÌÅÍÅ

ÍÈß ÏÐÎÒÈÂÍÈÊÎÌ ÁÀÊ. ÎÐÓÆÈß, ÐÅÇÓËÜÒÀÒÎÂ ÈÍÄÈÊÀÖÈÈ ÏÐÈÁÎÐÀ ÀÑÏ)
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(ÓÊÀÇÀÒÜ ÊÎËÈ×ÅÑÒÂÎ ÏÐÎÁ È ÊÓÄÀ
ÍÀÏÐÀÂËÅÍÛ)___________________________________________

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10. îòíîøåíèè âûÿâëåííûõ ýïèä. î÷àãîâ (ÊÎÍÊÐÅÒÍÛÅ ÍÎÇÎËÎÃÈ×ÅÑÊÈÅ
ÔÎÐÌÛ)___________

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___________________________________ïðîâåäåíî(ÓÊÀÇÀÒÜ ÏÅÐÅ×ÅÍÜ
ÏÐÎÂÅÄÅÍÍÛÕ ÌÅÐÎÏÐÈßÒÈÉ)______________

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(äîëæíîñòü)

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  (Â/çâàíèå,ïîäïèñü,äàòà)