Form 1E Attachment 1E Patient Screening (English)

Patient Screening Form

2019 Health Care Patient Survey

FRONT END:

PROGRAMMER: WE WILL NEED TO DEVELOP THE FOLLOWING VARIABLES FROM INORMATION GATHERED AT GRANTEE RECRUITMENT:

DEVELOP VARIABLE “FAC1”=NAME OF FACILITY [ALLOW 40]

DEVELOP VARIABLE “STATE” [ALLOW 2 CHARACTER STATE ABBREVIATION]

PROGRAMMER: DO NOT ALLOW DK OR REF RESPONSE FOR ANY OF THE SCREENER QUESTIONS.

INTERVIEWER: IF PATIENT REFUSES TO PARTICIPATE, DOCUMENT THE REASON FOR REFUSAL.

WHAT WAS THE MAIN REASON FOR THE PATIENT’S RESISTANCE?

¹        LACK OF INTEREST/UNCOOPERATIVE/NOTHING IN IT FOR ME

²        LACK OF TIME

³        FEAR OF A SCAM

⁴        privacy / confidentiality concerns /legitimacy

5 welfare/inc/ice/uscis concern

⁶        too sick/ill

⁷        DISLIKE OF THE SURVEY SPONSOR

⁸        DISLIKE OF THE SURVEY TOPICs

⁹        OTHER (SPECIFY: ____________500 CHARACTERS)

S_LANG.

BILINGUAL INTERVIEWER: ASK REPONDENT WHAT LANGUAGE HE/SHE IS MOST COMFORTABLE USING IN THE INTERVIEW.

What language would you want to be interviewed in?

SELECT 1 FOR ENGLISH

SELECT 2 FOR SPANISH

SELECT 3 FOR CHINESE - MANDARIN

SELECT 4 FOR CHINESE - CANTONESE

SELECT 5 FOR TAGALOG/FILIPINO

SELECT 6FOR VIETNAMESE

[NOTE TO PROGRAMMER: WE WILL BE USING THE SAME CHINESE INSTRUMENT FOR BOTH MANDARIN AND CHINESE. WE JUST NEED A MECHANISM IN THE SCREENER TO KEEP TRACK OF THE DIFFERENT TYPES OF INTERVIEWS.]

S1a. IS THIS A PROXY INTERVIEW?

1=YES [USE TO DEVELOP PROPER FILLS] -- CONTINUE

2=NO – GOTO S3

S1_child What is your child’s first name? I just need a way of referring to your child.

[Allow 20]

S3. Please tell me the age category that applies to {you/name}?

PROBE FOR BEST ESTIMATE, IF NECESSARY

IF UNABLE TO COMPLETE SCREENING, ENTER YOUR BEST GUESS BASED ON OBSERVATION

1=12 and under

2=13 to 17

3=18 to 34

4=35 to 49

5=50 to 64

6=65 and older

[IF NOT A PROXY INTERVIEW AND IF S3=1, PRESENT ERROR MESSAGE: “CHILDREN 12 YEARS OLD AND YOUNGER SHOULD ONLY BE INTERVIEWED THROUGH A PROXY.”]

RETURN TO S1a.

S_INT1.

The first few questions are for statistical purposes only, to help us analyze the results of the study.

Do you consider {yourself/name} to be Hispanic or Latino(a)?

1=YES

2=NO

S_INT2.

What race or races do you consider {yourself/name} to be? You may select all that apply.

{FILL: Are you/Is he/Is she}...

EXPLAIN, IF NECESSARY: “We ask this for statistical purposes only, to help us analyze the results of the study.”

NOTE: CODE “NATIVE AMERICAN” AS “AMERICAN INDIAN”

IF UNABLE TO COMPLETE SCREENING, ENTER YOUR BEST GUESS BASED ON OBSERVATION

1=White

2=Black or African American

3=American Indian or Alaska Native (American Indian includes North American, Central American, and South American Indians)

4=Native Hawaiian

5=Guamanian or Chamorro

6=Samoan

7=Tongan

8=Marshallese

9=Asian Indian

10=Chinese

11=Filipino

12=Japanese

13=Korean

14=Vietnamese

15=Other

S_INT2_OTH. [IF S_INT2_OTH=15]

[SOFT CHECK]: Can you tell be what other race or races you consider yourself to be?

FI: IF RESPONDENT MENTIONS MULTIPLE RACES THAT INCLUDE ONE OF THE RACES LISTED ABOVE, SELECT THE RACE THAT IS PROVIDED.

S_INT3.

IF SELF-RESPONDENT: RECORD; IF NOT OBVIOUS, ASK: What is your gender?

IF PROXY-RESPONDENT, ASK: What is {name’s} gender?

[SHOW ONLY FOR RESPONDENTS GE 13 YEARS OLD, NON PROXY INTERVIEWS:] IF R ANSWERS THAT THEYARE TRANSGENDER AND WHICH KIND IS NOT OBVIOUS – PROBE IF THEY ALTERED GENDER FROM MALE TO FEMALE OR FROM FEMALE TO MALE

IF UNABLE TO COMPLETE SCREENING, ENTER YOUR BEST GUESS BASED ON OBSERVATION

EXPLAIN, IF NECESSARY: “We ask this for statistical purposes only, to help us analyze the results of the study.”

1=MALE

2=FEMALE

3=OTHER

S1a. Have you ever served on active duty in the U.S. Armed Forces, military Reserves, or the National Guard?

IF NEEDED: Active duty does not include training for the Reserves or National Guard, but does include activation, for example, for the Persian Gulf War.

1=YES

2=NO

S1b. Thank you for your interest in participating in this patient survey. I have a few questions to determine whether or not {you are /name is} eligible.

{Have you}{Has your child} received services from a health care professional such as a doctor, nurse, drug counselor, mental health counselor, or dentist at {reference health center} in the last 12 months, that is since {12 MONTH REFERENCE DATE}?

1=YES

2=NO --- [GOTO END1 AND SET EVENT CODE TO 1320.]

S2_Intro Do any of the following apply to you?

S2a. Have you worked as a farmworker in the past 24 months or have you or has anyone in your family been supported by someone who worked as a farmworker in the past 24 months?

1=YES

2=NO

S2b. In the past 12 months, has there been a period in which you have been without regular housing or homeless? To clarify, that is not living in your own house, apartment, or room on a regular basis and not in a hospital or jail/prison. For example, living in a shelter, on the street/campsite/car/etc. or in temporary or transitional housing where services are provided.

1=YES

2=NO

S2c. Are you currently living in a public housing unit? Do not count Section 8 housing as public housing.

IF NEEDED, YOU MAY EXPLAIN: “Public housing is housing that is built, operated, and owned by a government and that is typically provided at nominal rent to the needy.”

1=YES

2=NO

S3. IF S3=6 (65 years of age or older) OR IF S1a=1 (Veteran) OR IF S_INT2=3,4,5,6,7,8,9,10,11,12,13, OR 14 (Asian/American Indian-Alaskan Native, Native Hawaiian or Pacific Islander) CONTINUE, ELSE GO TO S4_Intro.

You have been selected for an interview. Would you be able to complete the interview at this time?

1=YES [GO TO S5]

2=NO - BREAKOFF AND SCHEDULE A TIME TO INTERVIEW IN CMS

S4_Intro. INTERVIEWER: PLEASE ANSWER THE FOLLOWING QUESTIONS

S4a. HAS YOUR QUOTA BEEN MET FOR FARMWORKERS

1=YES

2=NO

3=no quota for this funding type

S4b. HAS YOUR QUOTA BEEN MET FOR HOMELESS

1=YES

2=NO

3=no quota for this funding type

S4c. HAS YOUR QUOTA BEEN MET FOR PUBLIC HOUSING

1=YES

2=NO

3=no quota for this funding type

S4d. HAS YOUR QUOTA BEEN MET FOR CHC

1=YES

2=NO

3=no quota for this funding type

NOTE TO PROGRAMMERS: THE FOLLOWING PRELOAD WILL COME FROM SAMPLING AS THEY DETERMINE WHAT FUNDING TYPE THIS SITE FALLS UNDER.

IF SITE = SINGLE FUNDING TYPE [FARMWORKER] THEN DEVELOP NEW VARIABLE “FARM0” AND GO TO S5, ELSE CONTINUE

IF SITE = SINGLE FUNDING TYPE [homeless] THEN DEVELOP NEW VARIABLE “HOME0” AND GO TO S5, ELSE CONTINUE

IF SITE = SINGLE FUNDING TYPE [public housing] THEN DEVELOP NEW VARIABLE “PUB0” AND GO TO S5, ELSE CONTINUE

IF SITE = SINGLE FUNDING TYPE [chc] THEN DEVELOP NEW VARIABLE “CHC0” AND GO TO S5, ELSE CONTINUE TO S4e.

S4e. SELECTION:

IF S2a=1 AND S4a=2 THEN CREATE NEW VARIABLE FARM1=1, ELSE FARM1=2

IF S2b=1 AND S4b=2 THEN CREATE NEW VARIABLE HOME1=1, ELSE HOME1=2

IF S2c=1 AND S4c=2 THEN CREATE NEW VARIABLE PUB1=1, ELSE PUB1=2

IF S4d=2 AND S2a = 2 AND S2b = 2 AND S2c = 2 THEN CREATE NEW VARIABLE CHC1=1, ELSE CHC1=2

if s4A-s4d all equal 1, then fill: “all OF YOUR quotas are filled. pLEASE DO NOT CONTINUE TO INTERVIEW AT THIS SITE.” SET EVENT CODE TO 1390

IF FARM1=2 and HOME1 = 2 and PUB1 = 2 and CHC1=2 THEN CREATE NEW VARIABLE CALLED PTYPE AND SET PTYPE TO EQUAL 5. SKIP TO END1.

IF FARM1=1 AND HOME1=2 AND PUB1=2 AND CHC=2, THEN SET PTYPE = 2 AND FILL: “You have been selected for an interview. Would you be able to complete the interview at this time? IF YES – PROCEED WITH INTERVIEW. IF NO – BREAKOFF AND SCHEDULE A TIME TO INTERVIEW IN CMS. RESPONDENT INTERVIEW SELECTED AS @UFARMWORKER@U – PLEASE UPDATE QUOTA AND CSR IF R AGREES TO PARTICIPATE AND CONTINUE WITH INTERVIEW.

IF HOME1=1 AND FARM1=2 AND PUB1=2 AND CHC=2 THEN SET PTYPE = 3 AND FILL: “You have been selected for an interview. Would you be able to complete the interview at this time? IF YES – PROCEED WITH INTERVIEW. IF NO – BREAKOFF AND SCHEDULE A TIME TO INTERVIEW IN CMS. RESPONDENT INTERVIEW SELECTED AS @UHOMELESS@U – PLEASE UPDATE QUOTA AND CSR IF R AGREES TO PARTICIPATE AND CONTINUE WITH INTERVIEW”

IF PUB1=1 AND HOME1=2 AND FARM1=2 AND CHC=2 THEN SET PTYPE = 1 AND FILL: “You have been selected for an interview. Would you be able to complete the interview at this time? IF YES – PROCEED WITH INTERVIEW. IF NO – BREAKOFF AND SCHEDULE A TIME TO INTERVIEW IN CMS. RESPONDENT INTERVIEW SELECTED AS @U PUBLIC HOUSING@U – PLEASE UPDATE QUOTA AND CSR IF R AGREES TO PARTICIPATE AND CONTINUE WITH INTERVIEW”

IF CHC1=1 AND S2b=2 AND S2c=2 AND S2a=2 THEN SET PTYPE = 4 AND FILL: “You have been selected for an interview. Would you be able to complete the interview at this time? IF YES – PROCEED WITH INTERVIEW. IF NO – BREAKOFF AND SCHEDULE A TIME TO INTERVIEW IN CMS. RESPONDENT INTERVIEW SELECTED AS @UCHC@U – PLEASE UPDATE QUOTA AND CSR IF R AGREES TO PARTICIPATE AND CONTINUE WITH INTERVIEW”

MULTIPLE SELECTION:

IF 2 OR MORE OF THE FOLLOWING: FARM1=1 AND/OR HOME1=1 AND/OR PUB1=1 AND/OR CHC1=1 THEN CONTINUE ELSE GOTO END1

SELECTION OF VARIABLES WHEN 2 OR MORE OF THE FOLLOWING (FARM1, HOME1, PUB1) = 1.

IF PUB1=1 THEN SET PTYPE = 1 AND FILL “You have been selected for an interview. Would you be able to complete the interview at this time? IF YES –PROCEED WITH INTERVIEW. IF NO – BREAKOFF AND SCHEDULE A TIME TO INTERVIEW IN CMS.

RESPONDENT INTERVIEW HAS BEEN SELECTED AS [FILL: @UPUBLIC HOUSING@U]”,

ELSE IF FARM1=1 THEN SET PTYPE = 2 AND FILL “You have been selected for an interview. Would you be able to complete the interview at this time? IF YES –PROCEED WITH INTERVIEW. IF NO – BREAKOFF AND SCHEDULE A TIME TO INTERVIEW IN CMS.

RESPONDENT INTERVIEW HAS BEEN SELECTED AS [FILL: @UMIGRANT@U]”,

ELSE IF HOME1=1 THEN SET PTYPE = 3 AND FILL “You have been selected for an interview. Would you be able to complete the interview at this time? IF YES –PROCEED WITH INTERVIEW. IF NO – BREAKOFF AND SCHEDULE A TIME TO INTERVIEW IN CMS.

RESPONDENT INTERVIEW HAS BEEN SELECTED AS [FILL: @UHOMELESS@U]”,

ELSE IF CHC1=1 THEN SET PTYPE = 4 AND FILL “You have been selected for an interview. Would you be able to complete the interview at this time? IF YES –PROCEED WITH INTERVIEW. IF NO – BREAKOFF AND SCHEDULE A TIME TO INTERVIEW IN CMS.

RESPONDENT INTERVIEW HAS BEEN SELECTED AS [FILL: @UCHC@U]”,

“PLEASE UPDATE QUOTA AND CSR IF R AGREES TO PARTICIPATE AND CONTINUE WITH INTERVIEW”

S4f.

IF FARM0: “You have been selected for an interview. Would you be able to complete the interview at this time? IF YES – PROCEED WITH INTERVIEW. IF NO – BREAKOFF AND SCHEDULE A TIME TO INTERVIEW IN CMS. RESPONDENT INTERVIEW SELECTED AS @UFARMWORKER@U – PLEASE UPDATE QUOTA AND CSR IF R AGREES TO PARTICIPATE AND CONTINUE TO S5.”;

IF HOME0: “You have been selected for an interview. Would you be able to complete the interview at this time? IF YES – PROCEED WITH INTERVIEW. IF NO – BREAKOFF AND SCHEDULE A TIME TO INTERVIEW IN CMS. RESPONDENT INTERVIEW SELECTED AS @UHOMELESS@U – PLEASE UPDATE QUOTA AND CSR IF R AGREES TO PARTICIPATE AND CONTINUE TO S5”;

IF PUB0: “You have been selected for an interview. Would you be able to complete the interview at this time? IF YES – PROCEED WITH INTERVIEW. IF NO – BREAKOFF AND SCHEDULE A TIME TO INTERVIEW IN CMS. RESPONDENT INTERVIEW SELECTED AS @UPUBLIC HOUSING@U – PLEASE UPDATE QUOTA AND CSR IF R AGREES TO PARTICIPATE AND CONTINUE TO S5”;

IF CHC0: “You have been selected for an interview. Would you be able to complete the interview at this time? IF YES – PROCEED WITH INTERVIEW. IF NO – BREAKOFF AND SCHEDULE A TIME TO INTERVIEW IN CMS. RESPONDENT INTERVIEW SELECTED AS @UCHC@U – PLEASE UPDATE QUOTA AND CSR IF R AGREES TO PARTICIPATE AND CONTINUE TO S5”;

S5. IF S3 = 2 CONTINUE

IF S3 = 1 GOTO INTRO1, ELSE GO TO INTRO2

Is a parent or guardian with you?

1=YES

2=NO

[IF S5=1 GOTO INTRO3, ELSE SET EVENT CODE=2231 UNACCOMPANIED MINOR AND GO TO END2]

END1 Thank you very much, but unfortunately you were not selected for interview.

END2 Thank you very much, but unfortunately we need to speak with your parent or guardian to gain their permission for you to continue with the interview.

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