Document Name Document Type
Form 6 Health Center Patient Survey Patient Screening Form Form
6 National_Patient Arrival and Referral Tracking Form Fina Attachment11 National_Patient Arrival and Referral Tracking Form Final_psg.docx Form
7 Final HCPS Screener_English_09302019_psg.docx Attachment 12 Final HCPS Screener_English_09302019_psg.docx Form
7 C Final HCPS Screener_Chinese_09302019_psg.docx Attachment 12 Final HCPS Screener_Chinese_09302019_psg.docx Form
7 S Final HCPS Screener_Spanish_09302019_psg.docx Attachment 12 Final HCPS Screener_Spanish_09302019_psg.docx Form
7 T Final HCPS Screener_Spanish_09302019_psg.docx Attachment 12 HCPS Patient Screener_Tagalog_psg.docx Form
7 V Final HCPS Screener_Vietnamese_09302019_psg.docx Attachment 12 Final HCPS Screener_Vietnamese_09302019_psg.docx Form
8 Informed Consent Form for Adult Survey Participation rev Attachment13_Informed Consent Form for Adult Survey Participation reviewed Final_psg.docx Form
8 C Informed Consent Form for Adult Survey Participation Fin Attachment 13 Informed Consent Form for Adult Survey Participation Final_TChinese_09272019_clean_psg.docx Form
8 S Informed Consent Form for Adult Survey Participation rev Attachment13_Informed Consent Form for Adult Survey Participation reviewed Final_SPANISH_09-27-2019_psg.docx Form
8 T _Informed Consent Form for Adult Survey Participation re Attachment 13 Informed Consent Form for Adult Survey Participation Tagalog_psg.docx Form
8 V Informed Consent Form for Adult Survey Participation VIE Attachment 13 Informed Consent Form for Adult Survey Participation VIE_09-27-2019_psg.docx Form
9 Informed Consent Form for Parent or Guardian Proxy revie Attachment13_Informed Consent Form for Parent or Guardian Proxy reviewed Final_psg.docx Form
9 C Informed Consent Form for Parent or Guardian Proxy Final Attachment 13 Informed Consent Form for Parent or Guardian Proxy Final_TChinese_09272019_clean_psg.docx Form
9 S Informed Consent Form for Parent or Guardian Proxy revie Attachment13_Informed Consent Form for Parent or Guardian Proxy reviewed Final_SPANISH_09-27-2019_psg.docx Form
9 T Informed Consent Form for Parent or Guardian Proxy Inter Attachment 13 Informed Consent Form for Parent or Guardian Proxy Interview for Accompanied Children Tagalog_psg.docx Form
9 V Informed Consent Form for Parent or Guardian Proxy VIE_0 Attachment 13 Informed Consent Form for Parent or Guardian Proxy VIE_09-27-2019_psg.docx Form
10 Parent or Guardian Permission form for Accompanied Adole Attachment13_Parent or Guardian Permission form for Accompanied Adolescent reviewed Final_psg.docx Form
10 S Parent or Guardian Permission form for Adolescent review Attachment13_Parent or Guardian Permission form for Adolescent reviewed Final_SPANISH_09-27-2019_psg.docx Form
10 T Parent or Guardian Permission Form for Adolescent Tagalo Attachment 13 Parent or Guardian Permission Form for Adolescent Tagalog_psg.docx Form
10 V Parent or Guardian Permission form for Adolescent Final Attachment 13 Parent or Guardian Permission form for Adolescent Final VIE_09-27-2019_psg.docx Form
10 C Parent or Guardian Permission form for Adolescent Final_ Attachment 13 Parent or Guardian Permission form for Adolescent Final_TChinese_09272019_clean_psg.docx Form
11 Assent Form for Accompanied Adolescent reviewed Final_ps Attachment13_Assent Form for Accompanied Adolescent reviewed Final_psg.docx Form
11 C Assent Form for Accompanied Adolescent Final_TChinese_09 Attachment 13 Assent Form for Accompanied Adolescent Final_TChinese_09272019_clean_psg.docx Form
11 S Assent Form for Accompanied Adolescent reviewed Final_SP Attachment13_Assent Form for Accompanied Adolescent reviewed Final_SPANISH_09-27-2019_psg.docx Form
11 V Assent form for Accompanied Adolescent VIE_09-27-2019_ps Attachment 13 Assent form for Accompanied Adolescent VIE_09-27-2019_psg.docx Form
12 Contact Summary Report Form Final_psg.docx Attachment 13 Contact Summary Report Form Final_psg.docx Form
Attachment 13 HCPS_brochure_2_4_19_GRAY_NoYr.pdf Attachment 13 HCPS_brochure_2_4_19_GRAY_NoYr IC Document

            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.