CURRENT CASE STATUS: CLOSED
CURRENT CASE STATUS: OPEN
INTERVIEW DETAILS - COMPLETED BY CHW
Referral Source Assigned CHW Interview Date / Time
Referral Source
* must provide value
South Bend DoH Clinic Mishawaka DoH Clinic La Casa Health Café Insurance Navigation Event CHW Referral Insurance Referral Physician Referral Lead Home Visit Wash Wednesday Other Home Visit Canvassing Phone Call Email School Food Pantry Lead Testing Event O'Brien Center Granger Wilson Primary Center Holy Family LaSalle Library Other
Assigned CHW
* must provide value
Jonathan Carmona Clara Davis Kim Dreibelbeis Mellisa Elissetche Veronica Escobedo Jennifer Gonzalez Savannah Hardy LaRhonda Hosea Jael Jackson Rafael Lemus Jackie Lopez Mercedes Lopez LaShawna Love Tracina Chism-Fikes Catherine Escobedo Jessica Robinson Other
Survey Begin Date/Time
* must provide value
Now M-D-Y H:M
Survey Location Today's Date Current Time
Doorhanger Flyer South Bend DoH Clinic Mishawaka DoH Clinic La Casa Health Café Lead Testing Event Lead Home Visit Wash Wednesday Woodrow Wilson Elem. School Other School Food Pantry Library Physician Office Women's Care Center Community Event Other
Today M-D-Y
Now H:M
IF THIS BOX IS SHOWING, PLEASE COPY THE ABOVE SURVEY DETAILS INTO THE PINK INTERVIEW DETAILS FIELDS ABOVE. THIS INFORMATION WAS SUBMITTED BY THE COMMUNITY MEMBER ON AN OUTWARD FACING SURVEY. PLEASE GET ADDITIONAL DETAILS FROM THE CM DURING YOUR 48 HOUR FOLLOW UP IF NECESSARY
SECTION 1 - PARTICIPANT INFORMATION
First Name Last Name Date of Birth
First Name
* must provide value
Last Name
* must provide value
Date of Birth
* must provide value
M-D-Y
Check All That Apply
Check All That Apply
Ethnicity
* must provide value
Gender
* must provide value
Female Male Transgender Non-Binary Prefer Not To Answer
PARENT / GUARDIAN NAME IF APPLICABLE
Parent / Guardian First Name Parent / Guardian Last Name
City State Zip Code How many people live in your household?
Approved Contact Method(s) (Please check all that apply)
Best time of day to contact?
Alternate / Emergency Phone Number
Apartment / Unit Number
Ardmore Argos Chain-O-Lakes Crest Manor Addition Crumstown Gilmer Park Granger Gulivoire Park Hi-View Addition La Paz La Paz Junction Lakeville Lydick Maple Lane Miami Trails Addition Midway Corners Mishawaka North Liberty Nutwood Orchard Heights Addition Pine Station Roseland South Bend Tamarack Grange Woodland Wyatt Other
State
* must provide value
IN Other
Zip Code
* must provide value
46544 46530 46614 46628 46545 46619 46637 46615 46561 46617 46613 46506 46574 46552 46556 46635 46601 46616 46554 46573 46536 46546 46595 46612 46604 46624 46620 46626 46634 46629 46680 46660 46699 Other
How many people live in your household?
* must provide value
1 2 3 4 5 6 7 8 9 10+
Phone Number
* must provide value
Phone Call Text Email In Person Online Other
H:M
ORIGINAL PREFERRED CONTACT METHOD
Population Details - Completed By CHW
CT 2 CT 20 CT 22 CT 24 CT 26 CT 30 CT 33 CT 34 CT 101 CT 102 CT 111 CT 115.01 CT 122 Other
SECTION 2 - SOCIAL NEEDS ASSESSMENT
Dou you currently have medical insurance? Do you currently have a primary care physician?
Do you have medical insurance?
Yes No
Yes No
Would you like assistance finding a primary care physician?
Yes No
YOU WILL REFER THEM TO A PRIMARY CARE PHYSICIAN DURING THE 48 HOUR FOLLOW UP
Insurance Carrier Type Insurance Carrier Name Insurance Carrier ID Number -coming soon-
How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?
Always Often Sometimes Rarely Never
Past Social Needs
Have you struggled with any of the following in the last THREE MONTHS:
(Please check all that apply)
Housing Family Healthcare
Financial Education / Safety
Check All That Apply
Check All That Apply
Check All That Apply
Check All That Apply
Check All That Apply
Past Education/Safety Needs
Check All That Apply
Present Social Needs
Do you CURRENTLY or EXPECT to need help with any of the following:
(Please check all that apply)
Housing Family Healthcare
Financial Education / Safety
Check All That Apply
Check All That Apply
Check All That Apply
Present Healthcare Needs 2
Check All That Apply
Check All That Apply
Present Education/Safety Needs
Check All That Apply
Do you have other social needs you might need assistance with? (PLEASE LEAVE BLANK IF NONE)
Do you have other social needs you'd like to have assistance with?
Additional Lead Questions
Have you or someone in your home had a recent lead test? Do you know the name of the Community Health Worker assigned to your lead case? Are you interested in a full lead assessment?
Yes No
Jonathan Carmona Clara Davis Kim Dreibelbeis Mellisa Elissetche Veronica Escobedo Jennifer Gonzalez Savannah Hardy LaRhonda Hosea Jael Jackson Rafael Lemus Jackie Lopez Mercedes Lopez LaShawna Love Tracina Chism-Fikes Catherine Escobedo Jessica Robinson Unsure Other
Yes No
First Name Last Name Lead Level Testing Location
South Bend DoH Clinic Mishawaka DoH Clinic Lead Testing Event Physician Office Other
Additional COVID-19 Questions
Have you been vaccinated against COVID-19? Have you or a loved one been diagnosed with COVID-19? Do you have any concerns about being able to stay healthy and/or safe from COVID-19? Have you had greater difficulties than usual in getting medical care during this time?
Yes No
Yes No
Yes No
Yes No
Are you concerned about the safety of the vaccine? Have you been able to access the vaccine?
Yes No
Yes No
Please click submit to complete the form.
Community Health Worker Notes
FOR ADMINISTRATIVE USE ONLY
Check here if case was assigned by Admin Personnel
Survey Complete Date/Time
Now M-D-Y H:M:S
Working...