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Fillable Printable Prapare Paper Form Sept 2016

Fillable Printable Prapare Paper Form Sept 2016

Prapare Paper Form Sept 2016

Prapare Paper Form Sept 2016

© 2016. National Association of Community Health Centers, Inc., Association of Asian Pacific Community Health Organizations,
and the Oregon Primary Care Association. PRAPARE and its resources are proprietary information of NACHC and its partners
intended for use by NACHC, its partners, and authorized recipients. Do not publish, copy, or distribute this information in part
or whole without prior written consent from NACHC. All rights reserved.
For more information about this tool, please visit our website at www.nachc.org/PRAPARE or contact Michelle Jester at
PRAPARE: Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences
Version 1.0
September 2, 2016
NOTE: THIS IS A WORKING DOCUMENT RESULTING FROM AN ITERATIVE PROCESS. PLEASE CHECK FOR
UPDATES AND CONTACT MICHELLE JESTER AT [email protected]G FOR MORE INFORMATION AND
TO JOIN THE MAILING LIST TO RECEIVE NOTIFICATIONS OF CHANGES.
Personal Characteristics
1. Are you Hispanic or Latino?
Yes
No
I choose not to answer this question.
OPTIONAL FeatureAdditional More Granular Response Choices that Roll-Up to Options Above:
See Appendix E of the IOM's 2009 report Race, Ethnicity, and Language Data:
Standardization for Health Care Quality Improvement (available at:
http://www.iom.edu/Reports/2009/RaceEthnicity Data.aspx) for a list of potential response
choices.
2. Which race(s) are you? Check all that apply.
Asian
Pacific Islander
American Indian/Alaskan Native
Other (please write)___________________
OPTIONAL FeatureAdditional More Granular Response Choices that Roll-Up to Options Above:
See Appendix E of the IOM's 2009 report Race, Ethnicity, and Language Data:
Standardization for Health Care Quality Improvement (available at:
http://www.iom.edu/Reports/2009/RaceEthnicity Data.aspx) for a list of potential response
choices.
© 2016. National Association of Community Health Centers, Inc., Association of Asian Pacific Community Health Organizations,
and the Oregon Primary Care Association. PRAPARE and its resources are proprietary information of NACHC and its partners
intended for use by NACHC, its partners, and authorized recipients. Do not publish, copy, or distribute this information in part
or whole without prior written consent from NACHC. All rights reserved.
For more information about this tool, please visit our website at www.nachc.org/PRAPARE or contact Michelle Jester at
3. At any point in the past 2 years, has seasonal or migrant farm work been your or your family’s
main source of income?
Yes
No
I choose not to answer this question.
[Definitions if needed for clarification:]
Migratory agricultural worker: is an individual whose principal employment is in agriculture
and who establishes a temporary home for the purposes of such employment. Migratory
agricultural workers are usually hired laborers who are paid piecework, hourly, or daily wages.
The family members may or may not move with the worker or establish a temporary home.
(according to section 330(g) of the Public Health Service Act)
Seasonal agricultural workers: individuals whose principal employment is in agriculture on a
seasonal basis (e.g. picking fruit during the limited months of a picking season) but who do not
establish a temporary home for purposes of employment. Seasonal agricultural workers are
usually hired laborers who are paid piecework, hourly, or daily wages. (according to section
330(g) of the Public Health Service Act)
4. Have you been discharged from the armed forces of the United States?
Yes
No
I choose not to answer this question.
5. What language are you most comfortable speaking? ___________________________________
English
Language other than English
(please write) ______________________
I choose not to answer this
question.
Family & Home
6. How many family members, including yourself, do you currently live with?
________________________________________
I choose not to answer this question.
© 2016. National Association of Community Health Centers, Inc., Association of Asian Pacific Community Health Organizations,
and the Oregon Primary Care Association. PRAPARE and its resources are proprietary information of NACHC and its partners
intended for use by NACHC, its partners, and authorized recipients. Do not publish, copy, or distribute this information in part
or whole without prior written consent from NACHC. All rights reserved.
For more information about this tool, please visit our website at www.nachc.org/PRAPARE or contact Michelle Jester at
7. What is your housing situation today?
I have housing
I do not have housing (staying with others, in a hotel, in a shelter, living outside on
the street, on a beach, in a car, or in a park)
I choose not to answer this question.
8. Are you worried about losing your housing?
Yes
No
I choose not to answer this question.
[Definitions if needed for clarification:]
Homeless Patients: Patients who lack housing (without regard to whether the individual is a member
of a family), including individuals whose primary residence during the night is a supervised public or
private facility that provides temporary living accommodations, and individuals who reside in
transitional housing.
“Homeless” for UDS reporting purposes, includes the following:
Shelter: Shelters for homeless persons are seen as temporary and generally provide for meals as
well as a place to sleep for a limited number of days and hours of the day that a resident may stay
at the shelter.
Transitional Housing: Transitional housing units are generally small units (six persons is
common) where persons who leave a shelter are provided extended housing staysgenerally
between 6 months and 2 yearsin a service rich environment. Transitional housing provides for a
greater level of independence than traditional shelters, and may require that the resident pay
some or all of the rent, participate in the maintenance of the facility and/or cook their own meals.
Count only those persons who are “transitioning” from a homeless environment. Do not include
those who are transitioning from jail, an institutional treatment program, the military, schools or
other institutions.
Doubled Up: Patients who are living with others; the arrangement is generally considered to be
temporary and unstable, though a patient may live in a succession of such arrangements over a
protracted period of time.
© 2016. National Association of Community Health Centers, Inc., Association of Asian Pacific Community Health Organizations,
and the Oregon Primary Care Association. PRAPARE and its resources are proprietary information of NACHC and its partners
intended for use by NACHC, its partners, and authorized recipients. Do not publish, copy, or distribute this information in part
or whole without prior written consent from NACHC. All rights reserved.
For more information about this tool, please visit our website at www.nachc.org/PRAPARE or contact Michelle Jester at
Street: This category includes patients who are living outdoors, in a car, in an encampment, in
makeshift housing/shelter, or in other places generally not deemed safe or fit for human occupancy.
Other: This category may be used to report previously homeless patients who were housed when
first seen, but who were still eligible for the Health Care for the Homeless program. Patients who
reside in SRO (single room occupancy) hotels or motels, other day-to-day paid housing, as well as
residents of permanent supportive housing or other housing programs that are targeted to
homeless populations should also be classified as “other”.
9. What address do you live at? (include street and zipcode)
___________________________________________
___________________________________________
Money & Resources
10. What is the highest level of school that you have finished?
Less than a high school degree
High school diploma or GED
More than high school
I choose not to answer this question.
11. What is your current work situation?
Unemployed and seeking work
Part time or temporary work
Full time work
Otherwise unemployed but not seeking
work (ex. student, retired, disabled,
unpaid primary care giver) Please
write____________________
I choose not to answer this question.
© 2016. National Association of Community Health Centers, Inc., Association of Asian Pacific Community Health Organizations,
and the Oregon Primary Care Association. PRAPARE and its resources are proprietary information of NACHC and its partners
intended for use by NACHC, its partners, and authorized recipients. Do not publish, copy, or distribute this information in part
or whole without prior written consent from NACHC. All rights reserved.
For more information about this tool, please visit our website at www.nachc.org/PRAPARE or contact Michelle Jester at
OPTIONAL FeatureAdditional Response Choices
Work less than 20 hours a week
Work 20-34 hours a week
Work 35-59 hours a week
Work 60 hours or more a week
OPTIONAL FeatureAdditional Question
How many jobs do you work?
1 job
3 or more jobs
2 jobs
I choose not to answer this question.
12. What is your main insurance?
1
None/uninsured
Medicaid
CHIP Medicaid
Medicare
Other public insurance (Not CHIP)
Other Public Insurance (CHIP)
Private insurance
OPTIONAL FeatureAdditional Question:
Do you have insurance through your job?
Yes
No
I choose not to answer this question.
1
If patient is unable to answer this question, health center staff can fill out this question by
pulling the information from the EHR or PMS.
© 2016. National Association of Community Health Centers, Inc., Association of Asian Pacific Community Health Organizations,
and the Oregon Primary Care Association. PRAPARE and its resources are proprietary information of NACHC and its partners
intended for use by NACHC, its partners, and authorized recipients. Do not publish, copy, or distribute this information in part
or whole without prior written consent from NACHC. All rights reserved.
For more information about this tool, please visit our website at www.nachc.org/PRAPARE or contact Michelle Jester at
13. During the past year, what was the total combined income for you and your family members
you live with? This information will help us determine if you are eligible for any benefits.
[NOTE: For organizations that already collect income for other purposes (sliding fee scale, insurance
eligibility, other benefits), please map that data such that patients are not asked about their income
multiple times. Please report percent of patients by Federal Poverty Level or FPL for PRAPARE
reporting purposes.]
__________________________________________
14. In the past year, have you or any family members you live with been unable to get any of the
following when it was really needed? Check all that apply.
Yes
No
Food
Yes
No
Clothing
Yes
No
Utilities
Yes
No
Child Care
Yes
No
Medicine or any health care (medical, dental, mental health, vision)
Yes
No
Phone
Yes
No
Other (please write)
___________________
I choose not to answer this question
15. Has lack of transportation kept you from medical appointments, meetings, work, or from getting
things needed for daily living? [Check all that apply]
Yes, it has kept me from medical appointments or from getting my medications
Yes, it has kept me from non-medical meetings, appointments, work, or from getting
things that I need
No
I choose not to answer this question
I choose not to answer this question.
© 2016. National Association of Community Health Centers, Inc., Association of Asian Pacific Community Health Organizations,
and the Oregon Primary Care Association. PRAPARE and its resources are proprietary information of NACHC and its partners
intended for use by NACHC, its partners, and authorized recipients. Do not publish, copy, or distribute this information in part
or whole without prior written consent from NACHC. All rights reserved.
For more information about this tool, please visit our website at www.nachc.org/PRAPARE or contact Michelle Jester at
Social and Emotional Health
16. How often do you see or talk to people that you care about and feel close to? (For example:
talking to friends on the phone, visiting friends or family, going to church or club meetings)
Less than once a week
1 or 2 times a week
3 to 5 times a week
More than 5 times a week
I choose not to answer this question.
17. Stress is when someone feels tense, nervous, anxious, or can’t sleep at night because their mind
is troubled. How stressed are you?
Not at all
Quite a bit
A little bit
Very much
Somewhat
I choose not to answer this question
OPTIONAL Feature: Additional Question
Ask the open-ended follow-up question “Who are the people or groups you usually see or talk to at
these times?”
© 2016. National Association of Community Health Centers, Inc., Association of Asian Pacific Community Health Organizations,
and the Oregon Primary Care Association. PRAPARE and its resources are proprietary information of NACHC and its partners
intended for use by NACHC, its partners, and authorized recipients. Do not publish, copy, or distribute this information in part
or whole without prior written consent from NACHC. All rights reserved.
For more information about this tool, please visit our website at www.nachc.org/PRAPARE or contact Michelle Jester at
Optional Questions
18. In the past year have you spent more than 2 nights in a row in a jail, prison, detention center, or
juvenile correctional facility?
Yes
No
I choose not to answer this question.
OPTIONAL Feature: Additional Question
What was your release date? __________________________
19. Are you a refugee?
Yes
No
I choose not to answer this question.
20. Do you feel physically and emotionally safe where you currently live?
Yes
No
Unsure
I choose not to answer this question
21. In the past year, have you been afraid of your partner or ex-partner?
Yes
No
Unsure
I have not had a partner in the past year
I choose not to answer this question
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