How much time did you spent with the patient? ___ minutes
Did you help the patient complete screening eligibility paperwork? □Yes □No If yes, how many minutes did it take to complete the eligibility paperwork?
Did you refer the patient for screening? □Yes □No If yes, what was the date of the referral? Date: _________ How many minutes did it take to refer the patient? _______ minutes
What barriers was the patient experiencing? [checklist with items such as transportation, childcare, elder care, lack of co-pay, insufficient health literacy]
How did you help the patient overcome these barriers? [checklist with items such as helped obtain bus tokens to pay for transportation, linked with certified childcare program to be at clinic during the patient’s appointment to care for the children, helped explain the information orally and escorted the patient to the correct section of the hospital (for patient who is unable to read a map)]
What was the interval from the referral date to the patient’s completion of the recommended screening? ____________ days/months/years (circle the latter)
Did you schedule the screening appointment for the patient? □Yes □No If yes, how long did it take to schedule the appointment? _____ minutes
Did you help the patient with transportation to or from the screening appointment? □Yes □No If yes, how many minutes did this take? _____ minutes
Did you drive the patient to and/or from the screening appointment? □Yes □No If yes, how many minutes did this take? _______ minutes
Did you accompany the patient into the clinic or van for their screening appointment? □;Yes □No If yes, how many minutes did this take? _____ minutes
Did the patient complete the screening? □Yes □No If yes, where will the tests results be stored? If no, why not?
How soon did the provider recommend the patient return for their next screening? □ within a month □ within 3 months □ within 6 months □ in 12 months □ Other (please specify ____________________)
