OMB CONTROL NUMBER: 0915-0368 EXPIRATION DATE: 03/31/2023
Patient Screening Form
2019 Health Care Patient Survey
FRONT END:
PROGRAMMER: PLEASE PRELOAD THE FOLLOWING VARIABLES FROM PATRICK’S SITE SELECTION AND QUOTA DATABASE/SPREADSHEET:
ClinicName
GranteeName
State
SeqID
CHC
MHC
PHPC
HCH
Quota_CHC
Quota_MHC
Quota_PHPC
Quota_HCH
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.
S_AGREE. DID RESPONDENT AGREE TO DO THE SCREENER?
YES (GO TO S_LANG)
NO (CONTINUE)
………….……………………………………………………………………………………………………
S_REF. 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 CONCERNED ABOUT CONTRACTING CORONAVIRUS (COVID-19)
10 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.
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 6 FOR 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 S_AGE
………….……………………………………………………………………………………………………
S1_child. What is {your/your child’s} first name? I just need a way of referring to {you/your child} during the interview. We only want {your/your child’s}first name.
[Allow 20]
[PROGRAMMER: PLACE AT BOTTOM OF S1_child:
(Public Burden Statement: The information collected through the Health Center Patient Survey (HCPS) informs HRSA on how health centers provide access to primary and preventative health care from the patients’ perspectives. It is the only nationally-representative survey of its type that focuses on the health care of populations seeking care at health centers. 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. The OMB control number for this information collection is 0915-0368 and it is valid until 03/31/2023. This information collection is voluntary. Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov.)
………….……………………………………………………………………………………………………
S_AGE. 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 S_AGE=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
3=GUESS BY FI-YES
4=GUESS BY FI-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
16=ANSWERS GUESSED BY FI – R OR PROXY REF
………….……………………………………………………………………………………………………
S_INT2_OTH. [IF S_INT2_OTH=15]
Can you tell me 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.
PROGRAMMER: IF RESPONDENT REFUSES SCREENER, CODE AS SCREENER REFUSAL (2410)
………….……………………………………………………………………………………………………
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 THEY ARE 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
………….……………………………………………………………………………………………………
S0. 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 person or via telehealth, in the last 12 months, that is since {12 MONTH REFERENCE DATE}? Telehealth includes services you received through audio or video communications with a health care professional from {reference health center} in the last 12 months.
1=YES
2=NO --- [GOTO END1 AND SET EVENT CODE TO 1320.]
………….……………………………………………………………………………………………………
S1c. center{reference health Think about your most recent visit, either in person or via telehealth, to }.
Was the reason for this visit due to concerns that you or someone you were in contact with may have been infected with the coronavirus disease or COVID-19 or needed COVID-19 services?
1=YES
2=NO
………….……………………………………………………………………………………………………
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
PROGRAMMER: PRELOADED DATA WILL BE INCLUDED IN 2019 TO DETERMINE THE FUNDING TYPE OF THE AGENCY. THE FUNDING TYPE COULD BE ONE OR MORE OF THE FOLLOWING: FARMWORKER (MHC), HOMELESS (HCH), OR PUBLIC HOUSING (PHPC). IF THE RESPONDENT ANSWERED “NO” TO S2a AND S2b AND S2c, THEN RESPONDENT SHOULD BE COUNTED TOWARDS CHC FUNDING TYPE (CHC).
IF RESPONDENT ANSWERED “YES” TO S2a OR S2b OR S2c THEN THEY WILL ONLY PROCEED TO S3 IF AGENCY HAS A COMPARABLE FUNDING TYPE [(S2a=YES AND MHC=YES) OR (S2b=YES AND HCH=YES) OR (S2c=YES AND PHPC=YES)] AND THERE IS A QUOTA FOR THAT FUNDING TYPE. IF THE FUNDING TYPE IS NOT PRELOADED THEN THIS SCREENER WILL END IN NO INTERVIEW - GOTO END1
FOR EXAMPLE, IN SCENARIO 1 THE RESPONDENT SELECTS “YES” FOR S2b AND THIS AGENCY PRELOAD INDICATES THAT THE AGENCY FUNDING TYPE IS “HOMELESS” (HCH=YES AND Quota_HCH>0), THEN THE SCREENER SHOULD PROCEED TO S3. IN SCENARIO 2 THE RESPONDENT SELECTS “YES” FOR S2a, BUT THE AGENCY FUNDING TYPE IS ‘PUBLIC HOUSING” (PHPC) THEN THIS IS A NON-INTERVIEW - GOTO END1
IF RESPONDENT MEETS CRITERIA FOR FUNDING TYPE ELIGIBILITY DESCRIBED ABOVE, THAT RESPONDENT WILL BE COUNTED TOWARDS THE QUOTA FOR THAT PARTICULAR FUNDING TYPE FOR THE SITE.
………….……………………………………………………………………………………………………
S3. IF S_AGE=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 S4e.
PROGRAMMER: CREATE A RUNNING COUNT OF RESPONDENTS WHO FALL UNDER EACH FUNDING TYPE:
MHC_COUNT
PHPC_COUNT
HCH_COUNT
CHC_COUNT
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 (MHC_COUNT <Quota_MCH) THEN CREATE NEW VARIABLE FARM1=1, ELSE FARM1=2
IF S2b=1 AND (HCH_COUNT<Quota_HCH) THEN CREATE NEW VARIABLE HOME1=1, ELSE HOME1=2
IF S2c=1 AND (PHPC_COUNT<Q uota_PHPC) THEN CREATE NEW VARIABLE PUB1=1, ELSE PUB1=2
IF (S2a=NO AND S2B=NO AND S2c=NO) AND (CHC_COUNT<Quota_CHC) THEN CREATE NEW VARIABLE CHC1=1, ELSE CHC1=2
if (MHC_COUNT>=Quota_MCH) AND (HCH_COUNT>=Quota_HCH) AND (PHPC_COUNT>=Quota_PHPC) AND (CHC_COUNT>=Quota_CHC), 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 AND S3 IS EMPTY, THEN CREATE NEW VARIABLE CALLED PTYPE AND SET PTYPE TO EQUAL 5. SKIP TO END1.
IF FARM1=2 and HOME1 = 2 and PUB1 = 2 and CHC1=2 and S3 not EMPTY THEN SET PTYPE = 6 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 – COMPLETE THE SCREENER AND SCHEDULE A TIME TO INTERVIEW IN CMS. RESPONDENT IS SELECTED @UWITH CERTAINTY@U.
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 – COMPLETE THE SCREENER 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 – COMPLETE THE SCREENER 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 – COMPLETE THE SCREENER 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 – COMPLETE THE SCREENER 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 – COMPLETE THE SCREENER 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 – COMPLETE THE SCREENER 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 – COMPLETE THE SCREENER 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 – COMPLETE THE SCREENER 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”
………….……………………………………………………………………………………………………
S5. IF S_AGE = 2 CONTINUE
IF S_AGE = 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.
………….…………………………………………………………………………………………………………
More codes were set during Screener:
IF S1b_Check = NO AND END1 = RESPONSE THEN Status= '2320' ('Inel No Service')
ELSEIF S4a = YES AND S4b = YES AND S4c = YES AND S4d = YES THEN Status= '1390' ('Ineligible')
ELSEIF Ptype = 5 THEN = '2348' ('Inel Non-Interv')
M
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Tim Flanigan |
| File Modified | 0000-00-00 |
| File Created | 2023-08-18 |