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General Information
First Name
Last Name
Title
Organization Name
Address
Organization Service Information
Primary population(s) served
AAPI
Not AAPI focused
Other
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Asian Indian
Bangladeshi
Bharat
Bhutanese
Burmese
Cambodian
Chinese
Dravidian
East Indian
Filipino
Goanese
Guamanian or Chamorro
Hmong
Indochinese
Indonesian
Iwojiman
Japanese
Korean
Laohmong
Laotian
Madagascar/Malagasy
Malaysian
Maldivian
Mong
Nepalese
Nipponese
Okinawan
Other Pacific Islander
Pakistani
Samoan
Siamese
Singaporean
Sri Lankan
Taiwanese
Thai
Vietnamese
Does your organization document the interventions, referrals, and/or other services you provide to address social determinants (e.g., transportation, housing, food insecurity, employment, etc.)? Check all that apply.
No, we do not track this work
Yes, we track social determinant interventions provided DIRECTLY by our organization
Yes, we track referrals to EXTERNAL social and community services not directly provided by our organization
Yes, we track whether patients or clients RECEIVE social services based on our organization’s referral
Yes, we track how much TIME our staff spend in either providing these services to patients/clients and/or helping patients/clients locate and receive social services
Yes, and we use a standard form to document our work to address social determinants. Please specify form/tool: ____________________
Please specify the form/tool used to document your work to address social determinants:
What would you like us to know about you and your organization?
Contact information
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