7 C Final HCPS Screener_Chinese_09302019_psg

OMB Number (0915-0368)
Expiration date (X/XX/XXXX)

（公共負擔聲明：通過健康中心患者調查（HCPS）收集的信息向HRSA通報了健康中心如何從患者的角度提供基本和預防性醫療服務。 這是該類型的唯一一次全國代表性調查，重點關注在保健中心尋求護理的人群的保健情況 機構不得進行或贊助資訊收集，個人無須對資訊收集作出回應，除非其顯示了目前有效的 OMB 控制號碼。此專案的 OMB 控制號碼為 0915-0368, 有效期至XX/XX/XXXX。此資訊收集出于自愿。此資訊收集的公共報告負擔預計平均需要60分鐘，包括瀏覽說明，搜尋現有資料資源，收集所需資料，以及完成並檢查該資訊收集的時間。向以下地址郵寄有關此負擔預計或此資訊收集的其他任何方面的評論，包括有關降低此負擔的建議：HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857, 或电郵[email protected].。）

Patient Screening Form - Chinese

Health Care Patient Survey

[PROGRAMMER: PLACE AT BOTTOM OF THIS FIRST SCREEN:

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)

PROGRAMMER: IF S_AGREE=2, SKIP TO S_AGE.

INTERVIEWER: IF REPONDENT REFUSES THE SCREENER, ANSWER THE NEXT QUESTIONS TO THE BEST OF YOUR ABILITY BASED ON OBSERVATION.

S_LANG.

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

請問您希望使用那種語言來進行面談？

SELECT 1 FOR ENGLISH

SELECT 2 FOR SPANISH

SELECT 3 FOR CHINESE - MANDARIN

SELECT 4 FOR CHINESE - CANTONESE

SELECT 5 FOR KOREAN

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 您孩子的名字是什麼？我只是需要一種稱呼您孩子的方式。

[Allow 20]

S3 請告訴我適用於{您/Name}的年齡類別？

PROBE FOR BEST ESTIMATE, IF NECESSARY

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

1=12 歲及以下

2=13 至 17 歲

3=18 至 34 歲

4=35 至 49 歲

5=50 至 64 歲

6=65 歲 及以上

[IF NOT A PROXY INTERVIEW AND IF S3=1, PRESENT ERROR MESSAGE:「12 歲及以下兒童僅應透過代理進行面談。」]

RETURN TO S1a.

S_INT1.

前面幾個問題僅作統計用途，以幫助我們分析研究結果。

您認為{您自己/姓名}是西班牙裔還是拉丁美洲裔？

1= YES

2= NO

S_INT2.

您認為{您自己/姓名}是哪個或哪些種族？您可以勾選所有適用項。

{FILL:您是/他是/她是}…

EXPLAIN, IF NECESSARY:「此問題僅作統計用途，以協助我們分析研究結果。」

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

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

1=白人

2=黑人或非裔美國人

3=美洲印第安人或阿拉斯加原住民（美洲印第安人包括北美洲、中美洲及南美洲印第安人）

4=夏威夷原住民

5=關島人或查莫洛人

6=薩摩亞人

7=東加人

8=馬紹爾人

9=亞洲印度人

10=華裔

11=菲律賓裔

12=日裔

13=韓裔

14=越南裔

15= 其它Other

S_INT2_OTH. [IF S_INT2_OTH=15]

[SOFT CHECK]: 您能告訴我您認為自己是其他哪個或哪些種族嗎？

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: 您是什麼性別？

IF PROXY-RESPONDENT, ASK: {姓名}是什麼性別？

[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: 「此問題僅作統計用途，以協助我們分析研究結果。」

1=男

2=女

3=Other

S1a. 您是否曾在美國武裝部隊、軍隊預備役或國家防衛隊擔任現役職務？

IF NEEDED: 現役職務並不包括後備役或國家防衛隊的訓練役，但包括參加過戰爭的現役軍人，例如參加過波斯灣戰爭。

1=YES

2=NO

S1b. 感謝您有意願參與這次病患調查。為確定{您/姓名}是否符合資格，我有一些問題要問。

過去 12 個月內，也就是從{12 MONTH REFERENCE DATE}起至今，{您是否}{您的孩子是否}在{參考健康中心}接受過醫生、護士、藥物顧問、精神健康顧問或牙醫等健康護理專業人員提供的服務？

1= YES

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

S2_Intro 請問下列任何情況是否適用於您？

S2a. 過去 24 個月內您是否做過農工，或者您或您家庭中的任何人是否曾讓在過去 24 個月內做過農工的某個人供養？

1= YES

2=NO

S2b. 過去 12 個月內，您是否曾有一段時期居無定所或無家可歸？說得更清楚一些，不是定期住在自己的房子、公寓或房間裡，也不是住在醫院裡或者囚禁在監獄中。例如，住在避難所裡，露宿街頭/營地/住在車裡/等，或者其它臨時或過渡性住所。

1= YES

2=NO

S2c. 您目前是否居住在公共住宅單元中？請勿將 Section 8 住房視為公共住房。

如果需要，您可以解釋：「公共住房是由政府建造、營運和擁有的，一般以極低的租金提供給貧困人群。」

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.

您已被選取進行面談。請問您現在是否能夠完成這次面談？

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:「您已被選取進行面談。請問您現在是否能夠完成這次面談？ 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:

「您已被選取進行面談。請問您現在是否能夠完成這次面談？ 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:「您已被選取進行面談。請問您現在是否能夠完成這次面談？ 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:「您已被選取進行面談。請問您現在是否能夠完成這次面談？ 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 「您已被選取進行面談。請問您現在是否能夠完成這次面談？ 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 「您已被選取進行面談。請問您現在是否能夠完成這次面談？ 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 「您已被選取進行面談。請問您現在是否能夠完成這次面談？ 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 「您已被選取進行面談。請問您現在是否能夠完成這次面談？ 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: 「您已被選取進行面談。請問您現在是否能夠完成這次面談？ 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:「您已被選取進行面談。請問您現在是否能夠完成這次面談？ 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: 「您已被選取進行面談。請問您現在是否能夠完成這次面談？ 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: 「您已被選取進行面談。請問您現在是否能夠完成這次面談？ 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

您的家長或監護人陪您一起嗎？

1= YES

2=NO

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

END1 非常感謝，但遺憾的是，您未被選取進行面談。

END2 非常感謝，但遺憾的是，我們需要先與您的家長或監護人面談，在獲得他們的許可後您才能繼續進行這次面談。