Patient Demographic Information Form

Integrating Community Pharmacists and Clinical Sites for Patient-Centered HIV Care

Att 5_Patient Demographic Information form

Patient Demographic Information Form

OMB: 0920-1019

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Attachment 5 Staff Project ID: __________

Clinic Project ID: __________





Form Approved

OMB No: 0920-XXXX

Exp. Date: XX/XX/XXXX







Patient Demographic Information











Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)



Patient Demographic Information



Date of Birth (month/year)

_____/ ______

Sex: (check all that apply)

Male

Female

Transgender

Race (check all that apply)

White

Black/African American

Asian

Native Hawaiian/Pacific Islander

American Indian/Alaska Native

Other: __________

Ethnicity

Hispanic/Latino

Not Hispanic/Latino

Unknown

Education level

less than high school

high school only

some college

college or above

Unknown

Number of people in household: _________ Unknown

Annual household income

< $15,000

$15,000 - < $30,000

$30,000

Unknown

Housing status

currently homeless

not currently, but homeless in the past 12 months

homeless previously, but not homeless in the past 12 months

Never homeless

Unknown

Employment status (check all that apply)

unemployed

employed

disabled

student

retired

Unknown

If patient is employed, is he/she employed part time or full time?

N/A

part time

full time

Unknown

Medical Insurance status (check all that apply)

Private insurance

Medicaid

Medicare

Ryan White/ADAP

uninsured

Unknown



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorCDC User
File Modified0000-00-00
File Created2021-01-25

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