Form 009_Sickle Cell_Cl 009_Sickle Cell_Cl 009_Sickle Cell_Client and Fam Comm Form

Sickle Cell Disease Program Evaluations

ATTACH_R_Family Communication for SCDTDP

Sickle Cell Disease Treatment Demonstration Program (SCDTDP) Evaluation - Client Family Communication Form

OMB: 0915-0344

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OMB Number: xxxx-xxxx

Expiration Date:


Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  The OMB control number for this project is 0915-xxxx.  Public reporting burden for this collection of information is estimated to average 30 minutes per respondent annually, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14-33, Rockville, Maryland, 20857.






Section G: CLIENT FAMILY COMMUNICATION


37. For Caregivers of clients under age 18

37. For Clients 18 years or older

The following questions pertain to clients under the age of 18 years and their caregivers. (Language categories provided below.)

  1. What is the primary spoken language in the client’s home? _________________________



  1. If English is not your primary language do you require a translator for medical services/medical information?

Yes No Not Applicable



What, if any, is the secondary spoken language? ________________________

  1. What language is the client/caregiver most comfortable reading?

Client: .

Don’t Know Not Applicable



Caregiver: .



  1. What is highest level of education attained?

Caregiver: .

Don’t Know Not Applicable



Continue to questions 38 and 39

The following questions pertain to the client 18 years of age or older. (Language categories provided below.)

  1. What is the primary spoken language in the client’s home? ____________________________



  1. If English is not your primary language do you require a translator for medical services/medical information?

Yes No Not Applicable



What, if any, is the secondary spoken language? _________________________



  1. What language are you most comfortable reading? _______________________________



  1. What is the highest level of education you attained? _______________________________



Continue to questions 38 and 39

*Language categories: American Sign Language, Arabic, Chinese, Haitian Creole, Igbo, Korean, Somali, Spanish, Vietnamese, Yoruba or please provide any other language not listed.

  1. Is the client of Hispanic, Latino, or Spanish origin?

No, not of Hispanic, Latino, or Spanish origin

Yes, Mexican, Mexican American Chicano Yes, Puerto Rican Yes, Cuban

Yes, another Hispanic, Latino, or Spanish origin- Print, for example, Argentinean, Colombian, Dominican, Nicaragua, Salvadoran, Spaniard, and so on.







  1. What is the client’s race? Mark (X) one or more boxes.

White Black or African American

American Indian or Alaska Native- Print name of enrolled or principal tribe.

_____________________________________________________________________

Asian Indian Japanese Native Hawaiian Chinese Korean

Guamanian or Chamorro Filipino Vietnamese Samoan

Other Asian- Print race, for example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on.

______________________________________________________________________

Other Pacific Islander- Print race, for example, Fijian, Tongan, and so on.

______________________________________________________________________

Some other race. Print race.

_______________________________________________________________________





File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorBrown, Lorraine (HRSA)
File Modified0000-00-00
File Created2021-02-01

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