MINERAL COUNTY MONTANA. Community Health Assessment
|
|
|
- Roland Simpson
- 5 years ago
- Views:
Transcription
1 MINERAL COUNTY MONTANA Community Health Assessment
2 Respondents by Gender 30% Female Male 70%
3 Respondents by Race/Ethnicity 1% 1% 0% 0% 1% White or Caucasian American Indian or Alaska Native Asian Black of African American Native Hawaiian or Pacific Islander Hispanic or Latino 97%
4 Respondents by Age 1% 25% 8% 11% 3% 14% 8% 11% 19%
5 Respondents by Number Living in the Household 2% 8% 3% 15% 13% 13% %
6 Respondents by Employment Status 5% 4% 1% 3% 0% 2% 13% 30% 7% 35% Employed Full Time Employed Part Time Retired Student Armed Forces/Military Self-Employed Stay at Home Parent Unable to Work Due to Illness/Injury Unemployed <1 Year Unemployed > 1 Year
7 Respondents by Zip Code 1% 4% 1% 10% 25% Alberton Superior St. Regis Haugan DeBorgia Saltese 59%
8 Respondents by Length of Time in the County 20% 52% 14% < 5 Years 5-10 Years Years 15+ Years 14%
9 Respondents by Highest Level of Education Attained 0% 1% 1% 29% 28% Never Attended School Grades 1-8 Grades 9-11 Grade 12 or GED Some College or Technical School College Graduate 41%
10 I Can Get the Health Care I Need in Mineral County 0% 1% 2% 42% 55% Strongly Agree Agree Disagree Strongly Disagree Don't Know
11 I Feel Safe in My Home 1% 0% 0% 34% 65% Strongly Agree Agree Disagree Strongly Disagree Don't Know
12 I Feel Safe in My Community 0% 1% 2% 42% 55% Strongly Agree Agree Disagree Strongly Disagree Don't Know
13 There are Places to be Physically Active Near My Home 1% 0% 5% 35% 59% Strongly Agree Agree Disagree Strongly Disagree Don't Know
14 I Have Enough Resources to Meet My Basic Needs 9% 2% 1% 44% Strongly Agree Agree Disagree Strongly Disagree 44% Don't Know
15 My Community is a Good Place to Raise Children 7% 0% 4% 42% Strongly Agree Agree Disagree Strongly Disagree Don't Know 47%
16 My Community is a Good Place to Grow Old 1% 3% 14% 40% Strongly Agree Agree Disagree Strongly Disagree Don't Know 42%
17 60.00% What is most important to a healthy community? 50.00% 40.00% 30.00% 20.00% 10.00% 0.00%
18 60.00% What would make our community a better place to grow old? 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% More social options Expanded medical services Transportation assistance Expanded senior center Ability to exercise Home meals
19 60.00% What would make our community a better place to raise children? 50.00% 40.00% 30.00% 20.00% 10.00% 0.00%
20 How would you describe your physical health? 1% 3% 9% 15% 27% Excellent Very Good Good Fair Poor Don't know 45%
21 90.00% What are the Community's most serious health concerns? 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00%
22 How often do you wear your seatbelt? 1% 0% 0% 2% 15% Always Nearly always Sometimes Seldom Never Never ride in a car 83%
23 Have you participated in physical activity in the last month? 13% Yes No 87%
24 In the last 7 days, how many days were you physically active? 5% 20% 42% 0 days 1-2 days 3-4 days 5 or more days 33%
25 45.00% What would help you be more physically active? 40.00% 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% More parks, trails, or greenways Walking or exercise group Access to gym More/better sidewalks More programs or events More sports leagues Stores within walking distance Increased neighborhood safety
26 What gets in the way of you being more physically active? 40.00% 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00%
27 30.00% What are the barriers to eating healthy? 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% There aren't places in my community to buy healthy food Healthy food costs too much It's hard to find healthy choices when you eat outside the home It takes too much time to prepare and shop for healthy choices I don't know how to prepare the food we like in a healthy way Nobody in my Healthy food does family would eat it not taste good
28 Are you aware of programs to help pay for health care expenses? 11% 21% Yes No Prefer not to say 68%
29 How long since your last routine check-up? 0% 5% 2% 11% Within the past year Within the past two years Within the past 5 years 5 or more years Never 82%
30 In the past 12 months was there a time when you could not get the health services you needed? 28% Yes No 72%
31 45.00% Reasons Why Health Care was Not Received 40.00% 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00%
32 60.00% What would improve access to healthcare? 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Availability of More primary care visiting specialists providers Availability of walk-in clinic Transportation assistance Improved quality of care Health education resources Telemedicine
33 60.00% What healthcare professionals or services presently NOT available in Mineral County would you use if they were available locally? 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Dentist Chiropractor Acupuncturist General Surgery OB/GYN Chronic Pain Specialist Diabetes Nurse Educator Colonoscopy Psychiatric Services
34 What preventative services have you used in the past year? 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00%
35 How long has it been since your last visit to the dentist? 1% 2% 15% 22% 60% Less than one year Within the past two years More than 5 years Don't know Never
36 35.00% What is the main reason you did not visit a dentist in the past year? 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00%
37 Do you use tobacco? 2% 18% Yes No Prefer not to say 80%
38 How often do you use cigarettes, chewing tobacco, or e-cigarettes? 13% Every Day Some days 87%
39 40.00% Where would you go for help to quit cigarettes, chewing tobacco, or e-cigarettes? 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% MT Quitline Other Health care provider Health Department
40 Do you feel that domestic violence is a problem in our community? 2% 33% 54% Yes No Don't know Prefer not to say 11%
41 80.00% What do you feel could be done to help those dealing with domestic violence? 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Holding abusers accountable Education for family/friends More education Safe housing Treatment for abusers Advocates to assist Help with finances
42 45.00% Where would you refer someone for domestic violence? 40.00% 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% Help line locally Mental health care provider Don't know Faith leader Medical provider YMCA Missoula Friend
43 Do you know where someone could go for mental health services? 21% 52% Yes No Don't know 27%
44 40.00% Where would you send someone for mental health services? 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% Choices for Partnership Health Change counseling Center Doctor/PA Don't know Faith based leader Emergency Room Friend
45 Do you know where someone could go for substance abuse services? 2% 29% 40% Yes No Don't know Prefer not to say 29%
46 50.00% Where would you refer someone for substance abuse services? 45.00% 40.00% 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% Alcoholics Anonymous Choices for Change counseling Partnership Health Center Don't know Doctor/PA Faith based leader Emergency Room Friend
47 80.00% What would be your top three choices of information in a disaster or emergency? 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Television Radio Neighbors Word of Mouth Social media Texts Other internet websites Newspaper Television website Don't know
48 80.00% How do you learn about health services or health-related information in our community? 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00%
49 35.00% Which educational classes would you be most interested in attending? 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00%
50 60.00% Which aging services are you aware of in Mineral County? 50.00% 40.00% 30.00% 20.00% 10.00% 0.00%
1. What is your ethnic origin? (Check one) 2. What is your gender? 3. What is your age? Page 1. nmlkj. nmlkj. nmlkj. nmlkj. nmlkj. nmlkj. nmlkj.
1. What is your ethnic origin? (Check one) White Asian/Pacfic Island American Indian Black Hispanic 2. What is your gender? Female Male 3. What is your age? 18 to 24 55 to 64 25 to 34 65 to 74 35 to 44
HCAHPS Survey SURVEY INSTRUCTIONS
HCAHPS Survey SURVEY INSTRUCTIONS You should only fill out this survey if you were the patient during the hospital stay named in the cover letter. Do not fill out this survey if you were not the patient.
Last Name First Name M.I. Name You Prefer. City State Zip Address. Daytime Phone Evening Phone Best Time to Call. City State If yes, where?
GENERAL INFORMATION Last Name First Name M.I. Name You Prefer Mailing Address How long at this address? City State Zip County If less than a year, previous address How long have you resided in the county?
Please answer each question completely and return to NOHN as soon as possible. Once we have received your completed
Thank you for participating in your Medicare Annual Wellness Visit with North Olympic Healthcare Network as recommended by your primary care provider. Your provider understands that as we age our preventive
HCAHPS Survey SURVEY INSTRUCTIONS
HCAHPS Survey SURVEY INSTRUCTIONS You should only fill out this survey if you were the patient during the hospital stay named in the cover letter. Do not fill out this survey if you were not the patient.
Virginia registered voters age 50+ support dedicating a larger proportion of Medicaid funding to home and community-based care.
2013 AARP Survey of Virginia Registered Voters Age 50+ on Long-Term Care Virginia registered voters age 50+ support dedicating a larger proportion of Medicaid funding to home and community-based care.
2018 LEAD: Nurses in Education and Practice Transitioning into Administrative Leadership Roles and Emerging Leaders
2018 LEAD: Nurses in Education and Practice Transitioning into Administrative Leadership Roles and Emerging Leaders Applicant Information Please complete this information. All information is required.
2015 All-Campus Career Fair Student Survey
2015 All-Campus Career Fair Student Survey Thank you for attending the All-Campus Career Fair on March 18th. The Career Center is interested in learning about your experience at the career fair and results
These documents contain the questions for the Illini Career and Internship Fair. At the University of Illinois at Urbana-Champaign
These documents contain the questions for the 2016 Illini Career and Internship Fair At the University of Illinois at Urbana-Champaign Questions are uploaded via CampusLabs and students fill out their
Survey of Program Training Needs (TCU PTN) Program Director Version (TCU PTN-D)
Survey of Program Training Needs (TCU PTN) Program Director Version (TCU PTN-D) To be completed by Program Director Please answer the following questions by filling in the circle that describes your substance
W e l c o m e t o B i l l e r i c a C h i r o p r a c t i c
W e l c o m e t o B i l l e r i c a C h i r o p r a c t i c N E W P A T I E N T I N T A K E F O R M Print Name Today s Date Address City State Zip Email Address Date of Birth Male Female Social Security
HOUSING AUTHORITY OF THE COUNTY OF SAN MATEO Instructions for a successful referral Permanent Supportive Housing Program (PSH)
Instructions for a successful referral Permanent Supportive Housing Program (PSH) The Permanent Supportive Housing Programs are rental assistance grants awarded and funded by the Department of Housing
INITIAL HEALTH SCREENING QUESTIONNAIRE
Welcome to. Now that you are a member, we ask that you please fill out this form. It will help us understand your needs and how to best support you with programs and services. If you need help completing
HELENE FULD COLLEGE OF NURSING
HELENE FULD COLLEGE OF NURSING APPLICATION FOR GENERIC BACHELOR OF SCIENCE (MAJOR IN NURSING) 24 East 120th Street, New York, NY 10035 Tel: 212-616-7200 Fax: 212-616-7299 www.helenefuld.edu PART I - BIOGRAPHICAL
Standards for Success ROSS Data Elements
This shortcut assists ROSS Grantees to identify: Relevant data elements to collect; Questions for gathering information for the data element; and Possible response options. Participant Description 1 Person
Manhattan-Staten Island Area Health Education Center
Name: First M.I. Last Ethnicity: Date of Birth: Age: Gender: American Indian or Alaskan Native / / M F Month Date Year Asian (Cambodia, Malaysia, Pakistan, Vietnam) Asian (China, Philippines, Japan, Korea,
College of Lake County Children s Learning Center Child Care Access Means Parents in School CCAMPIS Grant Application (Please print or type)
CCAMPIS# Date Received College of Lake County Children s Learning Center Child Care Access Means Parents in School CCAMPIS Grant Application (Please print or type) Approved Denied: Date: 1. Student-parent
RESPITE CARE VOUCHER PROGRAM
HELPING HANDS of VEGAS VALLEY 2320 Paseo Del Prado B-204, Las Vegas, NV 89102 (702) 633-7264 ext. 26 or Fax (702) 728-2963 RESPITE CARE VOUCHER PROGRAM Dear Applicant: Thank you for your interest in the
Additionally, the parent or legal guardian must provide the following documents upon registration of a new student:
Montgomery County Public Schools requires several documents upon registration of a new student. Below is a list of documents which may be downloaded and reviewed and/or completed by the parent or legal
BARNES-JEWISH HOSPITAL 2016 COMMUNITY HEALTH NEEDS ASSESSMENT & IMPLEMENTATION PLAN
BARNES-JEWISH HOSPITAL 2016 COMMUNITY HEALTH NEEDS ASSESSMENT & IMPLEMENTATION PLAN 1 TABLE OF CONTENTS Executive Summary... 3 Community Description... 4 Geography... 4 Population Trends... 5 Income...
APPLICATION FOR EMPLOYMENT
TICE TO APPLICANTS AND EMPLOYEES Screening tests for alcohol and illegal drug use may be required before hiring and during your employment here. APPLICATION FOR EMPLOYMENT We consider applications for
RHY Project Intake Form (Runaway & Homeless Youth Projects)
RHY Project Intake Form (Runaway & Homeless Youth Projects) Step 1: Universal Data Collection Please complete the following basic client information and note that all fields with an * are required fields.
EMPLOYMENT APPLICATION
EMPLOYMENT APPLICATION Page 1 of 3 This Employment Application will remain active for one year from the date of completion APPLICANT INFORMATION Last Name First M.I. Date Street Apartment/Unit # City State
16 th Annual Nurse Camp Application Packet Checklist
16 th Annual Nurse Camp Application Packet Checklist Only complete applications will be considered for Nurse Camp. Please double check your work to be sure you completed and included all required sections
Scientific Research Disaster Recovery Grant (Cycle 1) Contact Information
Scientific Research Disaster Recovery Grant (Cycle 1) Contact Information Applications Due: January 3, 2018, 5:00 PM ET Before the form is completed, you may click "Save & Continue" at the bottom of the
National After School Matters Fellowship Application
National Afterschool Matters Fellowship Application The National Afterschool Matters Fellowship is a collaborative effort between the National Institute of Out- of-school Time (NIOST) and the National
Oklahoma Department of Career and Technology Education
Oklahoma Department of Career and Technology Education Information Commons September 2016 Oklahoma Healthcare Support Occupations Parameters Occupations Code Description 31-0000 Healthcare Support Occupations
2018 Young Adult Employment Program Application
2018 Young Adult Employment Program Application The Young Adult Program receives state and federal funding to provide employment and training opportunities to low income and/or at-risk youth ages 16-24
Welcome Baby Prenatal Intake
Outreach Specialist: Welcome Baby Prenatal Intake Date: / / Length of visit: hour(s) minute(s) Attempted call #1: (date) Attempted call #2: (date) Attempted call #3: (date) Client name: DOB: / / Home address:
ALL MENTAL HEALTH AND SUBSTANCE USE DISORDER PROGRAMS MUST INCLUDE PSYCHOSOCIAL AND PSYCHIATRIC EVALUATIONS
COUNTY of NASSAU DEPARTMENT OF HUMAN SERVICES Office of Mental Health, Chemical Dependency and Developmental Disabilities Services 60 Charles Lindbergh Boulevard, Suite 200, Uniondale, New York 11553-3687
Oregon Community Based Care Communities Adult Foster Homes Survey
Oregon Community Based Care Communities Adult Foster Homes - 2014 Survey License No. Address of Foster Home Original License Date Operator Name Name of Home _ Home s Phone Fax Email Owner s Phone (if different)
PERSONAL INFORMATION Male Female
Please check the appropriate box to indicate which Drug Court Program applies to you. Adult Felony Post Plea Drug Court First time offenders (Do not check this box if you have more than one felony charge).
EQUAL EMPLOYMENT OPPORTUNITY DATA FORM Please Return to: City of Geneva Human Resources 22 South First Street Geneva, IL 60134
EQUAL EMPLOYMENT OPPORTUNITY DATA FORM Please Return to: City of Geneva Human Resources 22 South First Street Geneva, IL 60134 The following information will be used to determine the effectiveness of the
MESA Summer Academy: Solar System Mission Possible Application Deadline: June 1, 2018 Early Bird Discount Deadline: May 1, 2018
MESA Summer Academy: Solar System Mission Possible Application Deadline: June 1, 2018 Early Bird Discount Deadline: May 1, 2018 Program Description Get a head start on your career in space exploration
Please answer the survey questions about the care the patient received from this hospice: [NAME OF HOSPICE]
![Please answer the survey questions about the care the patient received from this hospice: [NAME OF HOSPICE]](/thumbs/79/80331294.jpg "Please answer the survey questions about the care the patient received from this hospice: [NAME OF HOSPICE]")
CAHPS Hospice Survey Please answer the survey questions about the care the patient received from this hospice: [NAME OF HOSPICE] All of the questions in this survey will ask about the experiences with
The National Study of Nursing Home Social Services
The National Study of Nursing Home Services The University of Iowa School of Work Contact information on back cover. START HERE Are you thesocialservicedirectororleadsocial services person on-site most
Voices of African Americans 50+ in North Carolina: Dreams & Challenges
2011 Voices of African Americans 50+ in North Carolina: Dreams & Challenges Executive Summary AARP has a strong commitment to help improve the lives of the 50+ population. As part of the Association s
Introduction. Please tell us about yourself. 1. What is your zip code? 2. What is your race or ethnic group? (Select all that apply.
Introduction Evaluation of the Lifespan Respite Care Program IRB Protocol.: X091222018 Explanation of Procedures: Greetings! Please reply to questions about your experience with respite services as a family
GENERAL GUIDELINES TO QUALIFY FOR HABITAT HOME REPAIR & WEATHERIZATION SERVICES:
Dear : Thank you for your interest in Habitat for Humanity Metro Maryland, Inc. s (HFHMM) Home Repair and Weatherization Programs. HFHMM weatherizes homes and provides low- or no-cost home repair services
UNIVERSAL INTAKE FORM
CLIENT DEMOGRAPHICS Agency Name: Fiscal Year: Funding Identifier: UNIVERSAL INTAKE FORM Title III B C1 C2 Title III D Title III E Title III E(G) 1 Linkages SNAP-Ed Applicant Last Name First Name Middle
Adult Health History
Adult Health History Name: DOB: Please list medications, including: vitamins, herbs, homeopathic remedies, and nonprescription medicines on the attached medication sheet. Medical History: High blood pressure
RESPITE CARE VOUCHER PROGRAM
HELPING HANDS of VEGAS VALLEY 2320 Paseo Del Prado B-204, Las Vegas, NV 89102 (702) 507-1848 or Fax (702) 728-2963 cory.lutz@hhovv.org RESPITE CARE VOUCHER PROGRAM Dear Applicant: Thank you for your interest
EMPLOYMENT APPLICATION
Travis County Human Resources Management Department 1010 Lavaca Street, 2 nd Floor (corner of West 11th & Lavaca) www.co.travis.tx.us P.O. Box 1748 Austin, TX 78767 (512) 854-9165 Voice EMPLOYMENT APPLICATION
HOMELESS VETERAN REGISTRY NORTHWEST MINNESOTA
STATE OF MINNESOTA MINNESOTA DEPARTMENT OF VETERANS AFFAIRS HOMELESS VETERAN REGISTRY NORTHWEST MINNESOTA TENNESSEN WARNING YOUR PRIVACY RIGHTS The State of Minnesota and its partners have committed to
March of Dimes Washington State Community Grants Program. Community Award Application
March of Dimes Washington State Community Grants Program March of Dimes Washington Kasey Rivas, MPH Maternal & Child Health Director 1904 Third Ave, Suite 230 Seattle, WA 98101 206-452-6631 krivas@marchofdimes.org
Saint Francis Medical Center College of Nursing Peoria, Illinois. Doctor of Nursing Practice. Application for Admission
Saint Francis Medical Center College of Nursing Peoria, Illinois Doctor of Nursing Practice Application for Admission 92016 Saint Francis Medical Center College of Nursing 511 N.E. Greenleaf Street, Peoria,
MEDICARE WELLNESS VISIT MEDICAL & HEALTH HISTORY
MEDICARE WELLNESS VISIT MEDICAL & HEALTH HISTORY **(To be completed by the patient, family member, or caregiver prior to seeing the doctor) * ACO Required *** Please te: This form is replaced by Annual
A. Are you currently a resident of the United States and 18 years of age and older?
The Polling Institute N=1,028 Likely Voters Saint Leo University Field: 10/22 10/26 October 2016 FLORIDA ballot measures The Polling Institute at Saint Leo University needs your help. We are conducting
Application For Employment
Application For Employment We consider applicants for all positions without regard to race, color, religion, creed, gender, genetics, national origin, age, disability, marital or veteran status, sexual
HCAHPS. Active Interactive Voice Response Script (English) Effective January 1, 2018 Discharges and Forward
HCAHPS Active Interactive Voice Response Script (English) Effective January 1, 2018 Discharges and Forward Overview This active interactive voice response (IVR) interview script is provided to assist operators
Capacity Building Grants: Education Contact Information
Capacity Building Grants: Education Contact Information Please remember to view the RFA and complete instructions on our website. Letter of Intent Due: February 14th, 2018, 5:00 PM ET Before the form is
Careers in Aging in Iowa. Careers in Aging: Social Work. Iowa s Population Census Bureau. Iowa 5/1/2013
Careers in Aging: Social Work Careers in Aging in Iowa Collaboration among: Iowa State University University of Northern Iowa Des Moines Area Community College University of Iowa Inspired by AGHE Association
Health Center Program Update
Health Center Program Update NACHC Policy & Issues Forum March 14, 2018 Jim Macrae Associate Administrator, Bureau of Primary Health Care (BPHC) Health Resources and Services Administration (HRSA) 3/22/2018
Cedars HOPE, Inc. RESIDENT APPLICATION
Cedars HOPE, Inc. RESIDENT APPLICATION Agency Name: Agency address: REFERRING AGECNY INFORMATION Fax: Referring Person Name: Contact Email Date of Referral: / / Name: APPLICANT INFORMATION Date of birth:
Certified Nursing Assistant (CNA) Program. Fall 2013 Demographics Survey
Certified Nursing Assistant (CNA) Program Fall 2013 Demographics Survey Prepared by Danielle Pearson Date: 10.17.2013 Introduction The Chaffey College Health Science Demographic Survey was completed by
MEDEX ACADEMY Undergraduate Application
Undergraduate Application Personal Information: Name: (Last) (First) (Middle) Preferred Name: Address: (Street) (Apt. Number) (City) (State) (Zip Code) Telephone: (Home) (Cell) (Other) E-mail: Date of
Primary care patient experience survey April 2016
Primary care patient experience survey April 2016 Survey overview 1. This version of the survey does not show the logic that skips people to appropriate questions based on their answers. Not all people
Physical Therapy Assistant Occupation Overview
Physical Therapy Assistant Occupation Overview Emsi Q1 2018 Data Set March 2018 Western Technical College 400 Seventh Street La Crosse, Wisconsin 54601 608.785.9200 Emsi Q1 2018 Data Set www.economicmodeling.com
Medicaid Transformation Waiver New options for Long-term Services and Supports. November 18th, 2016
Medicaid Transformation Waiver New options for Long-term Services and Supports November 18th, 2016 Today s topics Initiative 2 Long-Term Services and Supports Medicaid Alternative Care (MAC) Tailored Supports
PLEASE BE AWARE THAT YOU WILL NOT BE ABLE TO SAVE YOUR PROGRESS, SO PLEASE PREPARE ALL OF YOUR ANSWERS AND UPLOADABLE FILES IN ADVANCE.
2/26/2018 PhD Works Spring 2018 Application PhD Works Spring 2018 Application Your email address (lyl.tomlinson@stonybrook.edu) will be recorded when you submit this form. Not lyl.tomlinson? Sign out *
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) MBQIP Educational Session One Phase Two, January 2013
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) MBQIP Educational Session One Phase Two, January 2013 Overview HCAHPS (Hospital Consumer Assessment of Healthcare Providers and
MAIN STREET RADIOLOGY
MAIN STREET RADIOLOGY PATIENT REGISTRATION FORM **OFFICE USE ONLY** TODAY S DATE: MR#: LAST NAME: FIRST NAME: ADDRESS: APT: CITY: STATE: ZIP CODE: HOME PHONE #: ( ) - CELL PHONE#: ( ) - DATE OF BIRTH:
Client and Volunteer Satisfaction with the Poverello Medical Clinic
Client and Volunteer Satisfaction with the Poverello Medical Clinic Fall 2007 Community Benchmarks Program The Maxwell School of Syracuse University Research Team Kathleen O Connor Kerri Aronson Inessa
UNIVERSAL INTAKE FORM
Agency Name: Funding Identifier: Los Angeles County Area Agency on Aging UNIVERSAL INTAKE FORM Title IIIB Title C1 Title C2 Title IIIE Title IIIE(G) Linkages IDENTIFICATION DEMOGRAPHICS 1a Date: Applicant
Sage Medical Center New Patient Forms
Sage Medical Center New Patient Forms Patient Name: DOB: Providers and Suppliers of Your Medical Care: Please list all providers and suppliers of your medical care such as primary care physicians, specialty
RN-to-BSN PROGRAM APPLICATION
RN-to-BSN PROGRAM APPLICATION Personal Information Please provide your legal name below Middle Social Security Number Date of Birth Email Gender Religious Preference I am applying for the term beginning:
MILLERS COLLEGE OF NURSING
Congratulations on your decision to pursue your degree in nursing. The Millers College of Nursing offers a career pathway to meet the needs of individuals who are interested in obtaining the baccalaureate
Rhode Island Long-Term Care: An AARP Survey Data Collected by Woelfel Research, Inc. Report Prepared by Katherine Bridges
Rhode Island Long-Term Care: An AARP Survey Data Collected by Woelfel Research, Inc. Report Prepared by Katherine Bridges Copyright 2002 AARP Knowledge Management 601 E Street NW Washington, D.C., 20049
Administrative Billing Data
Administrative Billing Data Patient Identification and Demographic Information: From UB-04 Data or Medical Record Face Sheet. Note: When you go to enter data on this case, the information below will already
WikiLeaks Document Release
WikiLeaks Document Release 2, 2009 Congressional Research Service Report RS22452 United States Military Casualty Statistics: Operation Iraqi Freedom and Operation Enduring Freedom Hannah Fischer, Knowledge
School Based Health Consent for Services Grace Community Health Center, Inc.
School Based Health Consent for Services Grace Community Health Center, Inc. Please read carefully: In order for us to see your child in school based clinics, all pages of this form must be completed by
CPRS Application. Certified Peer Recovery Specialist. VCB CPRS Application Revised February
CPRS Application Certified Peer Recovery Specialist VCB CPRS Application Revised February 2017 - www.vacertboard.org - info@vacertboard.org 1 DIRECTIONS/CHECKLIST Documentation of high school diploma/ged
Home Health Quality Improvement Campaign
Home Health Quality Improvement Campaign Description of Monthly Report for Improvement in Oral Medications Monthly Report for Improvement in Management of Oral Medications All data displayed illustrate
Fogarty Global Health Fellowships NORTHERN/PACIFIC GLOBAL HEALTH RESEARCH FELLOWS TRAINING CONSORTIUM
Last Name: First Initial: Application Due Date: May 14, 2012 3:00PM ET *May 28 for international applicants Fogarty Global Health Fellowships NORTHERN/PACIFIC GLOBAL HEALTH RESEARCH FELLOWS TRAINING CONSORTIUM
Maricopa HMIS Project PATH Intake Form
1. Information Name and/or Alias SSN ID 2. Information Type Head of Relationship to Head of 3. Entry Summary Provider Name Couple (parent & friend) & child(ren) Couple with no child(ren) Extended family
Dear Kaniksu Patient,
Dear Kaniksu Patient, Welcome to Kaniksu Health Services (KHS), a Community Health Center that provides quality and affordable medical, pediatric, dental, behavioral health and veteran care, regardless
YOUR Recovery Residences
Resident Entry Form Resident Information Date of Entry Resident Name (First) (M) (Last) City State Zip Is your plan to return to this address following completion of your stay here? Y N If you go on overnight
AVI Systems, Inc. Employment Application
Employment Application 952-949-3700 9675 West 76th Street, Suite 200 Eden Prairie, MN 55344 www.avisystems.com Applicant Information Date: Last First M.I. Street Address Apt/Unit # City State ZIP Code
Hospitals Collaborating to Assess and Address Changing Community Health Needs
Hospitals Collaborating to Assess and Address Changing Community Health Needs MARGARET DROZD, MSN, RN, APRN-BC DIRECTOR COMMUNITY MOBILE HEALTH SERVICES SAINT PETER S UNIVERSITY HOSPITAL Hospitals Collaborating
North Shore Community Health Priority Assessment
North Shore Community Health Priority Assessment 2017-2021 1 Letter from the Health Director/Officer In 2017, the North Shore Health Department began the process of creating a North Shore Community Health
WHITMAN COUNTY CIVIL SERVICE COMMISSION
WHITMAN COUNTY CIVIL SERVICE COMMISSION In compliance with Federal and State equal employment opportunity guidelines, qualified applicants are considered for employment without regards to race, creed,
Responsible Party Information (Information used for patient balance statements) Responsible Party Another Patient Guarantor Self
Patient Information (Please Print) Dr. Miss Mr. Mrs. Sir Patient s Name (Last) (First) (MI) Previous Name Address Line 1 City, State ZIP Home Phone Cell No. Work Phone Ext. Primary Care Provider (PCP)
Minnesota State Colleges and Universities Consortium Doctor of Nursing Practice Program Program Application Application Due March 15, 2009
Minnesota State Colleges and Universities Consortium Doctor of Nursing Practice Program 2009-2010 Program Application Application Due March 15, 2009 1. Name: (Last) (First) (Middle Initial) (Maiden/Other)
SCHOOL OF NURSING POLICY
SCHOOL OF NURSING POLICY SUBJECT: Academic Affairs TITLE: Graduate Program Student Scholarship Responsible Executive: Assistant Dean for Graduate Programs Responsible Office: Business Office CODING: 06-01-05-16:00
All requests will be submitted electronically by IUF. IU ERA: Routing Form - Tracking Number (required only for requests moving to full proposal):
Per Lilly s request, they will accept requests from the Bloomington and Indianapolis campuses only. The College of Arts and Sciences and the Kelley School may submit multiple requests per funding round.
Welcome Letter- Orchard School Clinic
Welcome Letter- Orchard School Clinic Dear Parent or Guardian: Orchard School Clinic is a school-based location of RiverStone Health Clinic. This is a collaborative effort between RiverStone Health, Billings
Young, Beginning, Small and Minority Farmer elearning Course Ag Biz Planner
Young, Beginning, Small and Minority Farmer elearning Course Ag Biz Planner Ag Biz Planner Program Goals: Assist young, beginning, small and minority farmers in becoming more successful business people
Standard Penn State Poll Demographic Questions/Recodes Included in the Per Question Cost
Before we begin, I need to make sure that you live in Pennsylvania. What county do you live in? Adams... 1 Allegheny... 2 Armstrong... 3 Beaver... 4 Bedford... 5 Berks... 6 Blair... 7 Bradford... 8 Bucks...
COMMUNITY DEVELOPMENT BLOCK GRANT PROGRAM YEAR 2016/17
COMMUNITY DEVELOPMENT BLOCK GRANT PROGRAM YEAR 2016/17 ANNUAL REPORT CDBG subrecipients, please fill in the following tables and answer questions as completely as possible. Submit this report to the City
HARBOR CARE HEALTH & WELLNESS CENTER Patient Intake Form Please print clearly. Please ask for assistance in completing this form if needed.
Today date: HARBOR CARE HEALTH & WELLNESS CENTER Patient Intake Form Please print clearly. Please ask for assistance in completing this form if needed. Patient Full Name: Of Birth: Street: City: Zip Code:
COLLEGE MENTAL HEALTH PROGRAMS APPLICATION
Boston University College of Health & Rehabilitation Sciences: Sargent College Center for Psychiatric Rehabilitation Stephanie Cummings, Administrative Manager Recovery Services Division 940 Commonwealth
HEALTH HISTORY QUESTIONNAIRE
Patient Name: of Birth: HEALTH HISTORY QUESTIONNAIRE Primary Care Physician: Other physicians you currently see: Emergency Phone #: Contact Person/Relationship: Reason for the Visit: Please list your medications
FAITH IN PREVENTION PROGRAM Faithful Families Eating Smart and Moving More
FAITH IN PREVENTION PROGRAM REQUEST FOR APPLICATIONS Faith-Based Organization Mini-Grants I. OVERVIEW: With support from the New Jersey Department of Health (NJ DOH), Public Health Services, and Division
Licensed Nursing Assistant Renewal/Reinstatement Application
Vermont Secretary of State Attn: Renewal Clerk Office of Professional Regulation 89 Main St. 3 rd Floor Montpelier, VT 05620-3402 Licensed Nursing Assistant Renewal/Reinstatement Application Board of Nursing
Pediatric New Patient Intake Form
Name: DOB: Page 1 of 5 Pediatric New Patient Intake Form Patient Information Last Name: First Name: DOB: Home Mobile Preferred (circle) : Home / Cell Email: Gender: Primary Pediatrician: Pediatrician Address:
Thanks for your interest in Walk Across Texas!
Thanks for your interest in Walk Across Texas! Walk Across Texas! is an eight-week walking program for teams of up to eight people. One member of the team needs to be the team captain. Members of a team
Alabama A&M University Student Academic Program Assessment Electrical Engineering Technology
I. Degree program type: 1 Undergraduate 5 100% 2 Graduate 0 0% Mean 1.00 Gender: 1 Male 3 75% 2 Female 1 25% Mean 1.25 Age group: 1 18-20 0 0% 2 21-23 1 20% 3 24-25 1 20% 4 26-30 2 40% 5 31-40 1 20% 6
PLEASE BE AWARE THAT YOU WILL NOT BE ABLE TO SAVE YOUR PROGRESS, SO PLEASE PREPARE ALL OF YOUR ANSWERS AND UPLOADABLE FILES IN ADVANCE.
6/12/2018 PhD Works Summer 2018 Application PhD Works Summer 2018 Application Your email address (lyl.tomlinson@stonybrook.edu) will be recorded when you submit this form. Not lyl.tomlinson? Sign out *
March of Dimes Chapter Community Grants Program Letter of Intent (LOI)
March of Dimes Chapter Community Grants Program 2016 Letter of Intent (LOI) March of Dimes Michigan Chapter 26261 Evergreen Rd., #290 Southfield, MI 48076 (248) 359-1550 khamiltonmcgraw@marchofdimes.org
University of Idaho Survey of Staff
University of Idaho Survey of Staff 2016 Staff Survey Contents Overall Satisfaction with Employment... 2 2 Year Turnover... 3 Reason You Might Leave UI... 4 Satisfaction with Aspects of Job... 5 Available