Form Approved
OMB No. 0955-XXXX
Exp. Date TBD
Access, Exchange, and Use of Social Determinants of Health Data in Clinical Notes (SDOH)
Patients and Care Partners Prescreening Questionnaire (English)
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0955-XXXX. The time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.
PRESCREENING QUESTIONNAIRE-Patients and Care Partners (English)
What is your name?
What is your email address?
What is your phone number?
What is your zip code?
What is your date of birth? (terminate if younger than age 18)
What is your race? (can pick more than 1)
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or other Pacific Islander
Other: _________
Prefer not to answer
Are you of Hispanic, Latino, or Spanish ethnicity?
Yes
No
Prefer not to answer
What sex were you assigned at birth, on your original birth certificate?
Female
Male
How do you describe yourself?
Female
Male
Transgender
Do not identify as female, male or transgender
Prefer not to answer
What is your sexual orientation?
Heterosexual or straight
Gay or lesbian
Bisexual
Prefer not to answer
Do you speak a language other than English at home?
Yes
No
[If yes] Do you speak Spanish at home?
Yes
No
Which of the following best describes the location where you live?
Urban
Suburban
Rural
Are you deaf or do you have serious difficulty hearing?
Yes
No
Are you blind or do you have serious difficulty seeing even when wearing glasses?
Yes
No
Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?
Yes
No
Do you have serious difficulty walking or climbing stairs?
Yes
No
Do you have difficulty dressing or bathing?
Yes
No
Because of a physical, mental or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?
Yes
No
Do you have two or more chronic health care conditions?
Yes
No
Are you a caregiver of a child below the age of 18?
Yes
No
What was your total household income last year?
$0 – $24,999
$25,000-$49,999
$50,000-$74,999
$75,000-$99,999
$100,000-124,999
$125,000 or more
Prefer not to answer
Prescreening Questionnaire-Clinicians/Healthcare Professionals
What is your name?
What is your email address?
What is your phone number?
What is your zip code?
What is your race? (can pick more than 1)
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or other Pacific Islander
Other: _________
Prefer not to answer
Are you of Hispanic, Latino, or Spanish ethnicity?
Yes
No
Prefer not to answer
How do you describe yourself?
Female
Male
Transgender
Do not identify as female, male or transgender
Prefer not to answer
Are you a physician?
Yes
No
(if yes) In what specialty are you licensed to practice? (can choose more than 1)
Internal medicine/Primary care (adult)
Pediatrics
Emergency medicine
Surgery
Psychiatry
Other: ____________
(if no)
Are you a: (can choose more than 1)
Registered nurse
Physician assistant
Advanced practice registered nurse
Licensed social worker
Emergency management technician
Psychologist
Physical therapist
Occupational therapist
Registered dietician nutritionist
Other: ____________
Do you have any of the following roles within your organization? (can choose more than 1)
Care or case manager
Discharge planner
Community resource specialist
Which of the following best describes the setting where you provide care? (can choose more than 1)
Academic/Teaching hospital (or affiliated outpatient practice)
Private or Public Community-based hospital (or affiliated outpatient practice)
Public, Safety Net Hospital (or affiliated outpatient practice)
Private practice no hospital affiliation
Federally qualified health center
Community-based social services organization
Community-based behavioral health organization
Emergency services organization
Which of the following best describes the location where you work?
Urban
Suburban
Rural
What is the size of your organization?
Solo practice or 2 clinician practice
Small group practice (10 or fewer clinicians)
Multispecialty practice with more than 10 clinicians
Other: ______________________________
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | LeRoy Wong |
| File Modified | 0000-00-00 |
| File Created | 2021-11-01 |