Refugee HOMES Data Entry Form Survey

1. PATIENT'S AGE

PATIENT'S AGE

2. PATIENT'S GENDER

PATIENT'S GENDER Male

Female

Transgendered/Intersex

Other (please specify)

3. PATIENT'S IMMIGRATION STATUS

PATIENT'S IMMIGRATION STATUS STATUS UNKNOWN OR UNSURE

REFUGEE CLAIMANT (awaiting decision), country of origin not known

REFUGEE CLAIMANT (awaiting decision), from Designated Country of Origin

REFUGEE CLAIMANT (awaiting decision), NOT from Designated Country of Origin

REJECTED REFUGEE CLAIMANT (negative decision)

RESETTLED REFUGEE (Government Assisted Refugee or Privately Sponsored Refugee)

REFUGEE (claim accepted – Convention refugee or protected person)

Please specify country of origin below (if known):

4. CONDITION MOST RESPONSIBLE FOR ADVERSE OUTCOME (e.g. diabetes, PTSD, coronary artery disease, pregnancy)

CONDITION MOST RESPONSIBLE FOR ADVERSE OUTCOME (e.g. diabetes, PTSD, coronary artery disease, pregnancy)

5. ADVERSE OUTCOME CLASSIFICATION (check all that apply)

ADVERSE OUTCOME CLASSIFICATION (check all that apply) DECREASED FUNCTIONING (e.g. reduced ability to care for dependents)

DETERIORATION OF CHRONIC PHYSICAL CONDITION (e.g. poor symptom control in asthma patient)

DETERIORATION OF CHRONIC MENTAL CONDITION (e.g. worsening of PTSD symptoms)

ACUTE MEDICAL EVENT (e.g. myocardial infarction, stroke, COPD exacerbation)

ACUTE MENTAL HEALTH CRISIS (e.g. suicidality)

AVOIDABLE EMERGENCY ROOM VISIT

AVOIDABLE HOSPITALIZATION

AVOIDABLE INTENSIVE CARE UNIT TRANSFER

AVOIDABLE PROCEDURE OR SURGERY

DEATH

Other (please specify)

6. DESCRIBE ADVERSE OUTCOME AND SEVERITY OR IMPACT (e.g. stroke, right-sided weakness). For deaths, include cause of death if known.

DESCRIBE ADVERSE OUTCOME AND SEVERITY OR IMPACT (e.g. stroke, right-sided weakness). For deaths, include cause of death if known.

7. In your opinion, COULD THIS ADVERSE OUTCOME HAVE BEEN PREVENTED?

In your opinion, COULD THIS ADVERSE OUTCOME HAVE BEEN PREVENTED? NO - not preventable

YES - could have been prevented by better access to MEDICATION

YES - could have been prevented by better access to care for a CHRONIC CONDITION

YES - could have been prevented by better access to care for an ACUTE CONDITION

CANNOT DETERMINE

Other (please specify)

8. NARRATIVE DESCRIPTION OF ADVERSE OUTCOME and explanation of how it could have (or why it could not have) been prevented by better access to healthcare. Do not include any information that could be used to identify an individual patient.

NARRATIVE DESCRIPTION OF ADVERSE OUTCOME and explanation of how it could have (or why it could not have) been prevented by better access to healthcare. Do not include any information that could be used to identify an individual patient.

9. YOUR NAME, QUALIFICATIONS, AND CONTACT INFORMATION (email, phone, fax, and mailing address).This information may be used to verify the accuracy of information on this form or to obtain additional information about the adverse outcome but it will not be used for any other purpose. Please indicate if you, the patient or a representative of the patient are willing to provide additional information. Do not include any information that could be used to identify an individual patient.

YOUR NAME, QUALIFICATIONS, AND CONTACT INFORMATION (email, phone, fax, and mailing address).This information may be used to verify the accuracy of information on this form or to obtain additional information about the adverse outcome but it will not be used for any other purpose. Please indicate if you, the patient or a representative of the patient are willing to provide additional information. Do not include any information that could be used to identify an individual patient.

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Refugee HOMES Data Entry Form
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