Assignment Paper: Assessment/Interview

Provider Interview Acknowledgement Form

Student Name: __________________	Section & Faculty Name:_________________________________
Date of Interview: ________________
Provider Information
Provider Name :
Last	First	M.I.
Credentials:		Title:
(i.e. MS, RN, etc.)
Organization:
Phone Number:
E-mail Address:
Interview Acknowledgement

I _______________________acknowledge that I was interviewed by _____________________on the

(Provider Name) (Student Name)

date listed above. The organization / agency does not endorse the university or the student however, the student learning experience is considered appropriate for educational purposes.

______________________________ _________________

Provider Signature Date Signed

NOTE:

Acknowledgement form is to be returned to the student for electronic submission to the faculty member.

Functional Health Patterns Community Assessment Guide

Functional Health Pattern (FHP) Template Directions:

This FHP template is to be used for organizing community assessment data in preparation for completion of your collaborative learning community (CLC) assignment. Address every bulleted statement in each section with data or rationale for deferral. You may also add additional bullet points if applicable to your community. Assignment Paper: Assessment/Interview

Value/Belief Pattern

· Predominant ethnic and cultural groups along with beliefs related to health.

· Predominant spiritual beliefs in the community that may influence health.

· Availability of spiritual resources within or near the community (churches/chapels, synagogues, chaplains, Bible studies, sacraments, self-help groups, support groups, etc.).

· Do the community members value health promotion measures? What is the evidence that they do or do not (e.g., involvement in education, fundraising events, etc.)?

· What does the community value? How is this evident?

· On what do the community members spend their money? Are funds adequate?

Health Perception/Management

· Predominant health problems: Compare at least one health problem to a credible statistic (CDC, county, or state).

· Immunization rates (age appropriate).

· Appropriate death rates and causes, if applicable.

· Prevention programs (dental, fire, fitness, safety, etc.): Does the community think these are sufficient?

· Available health professionals, health resources within the community, and usage.

· Common referrals to outside agencies.

Nutrition/Metabolic

· Indicators of nutrient deficiencies.

· Obesity rates or percentages: Compare to CDC statistics.

· Affordability of food/available discounts or food programs and usage (e.g., WIC, food boxes, soup kitchens, meals-on-wheels, food stamps, senior discounts, employee discounts, etc.).

· Availability of water (e.g., number and quality of drinking fountains).

· Fast food and junk food accessibility (vending machines).

· Evidence of healthy food consumption or unhealthy food consumption (trash, long lines, observations, etc.).

· Provisions for special diets, if applicable.

· For schools (in addition to above):

· Nutritional content of food in cafeteria and vending machines: Compare to ARS 15-242/The Arizona Nutrition Standards (or other state standards based on residence)

· Amount of free or reduced lunch

Elimination (Environmental Health Concerns)

· Common air contaminants’ impact on the community.

· Noise.

· Waste disposal.

· Pest control: Is the community notified of pesticides usage?

· Hygiene practices (laundry services, hand washing, etc.).

· Bathrooms: Number of bathrooms; inspect for cleanliness, supplies, if possible.

· Universal precaution practices of health providers, teachers, members (if applicable).

· Temperature controls (e.g., within buildings, outside shade structures).

· Safety (committee, security guards, crossing guards, badges, locked campuses).

Activity/Exercise

· Community fitness programs (gym discounts, P.E., recess, sports, access to YMCA, etc.).

· Recreational facilities and usage (gym, playgrounds, bike paths, hiking trails, courts, pools, etc.).

· Safety programs (rules and regulations, safety training, incentives, athletic trainers, etc.).

· Injury statistics or most common injuries.

· Evidence of sedentary leisure activities (amount of time watching TV, videos, and computer).

· Means of transportation.

Sleep/Rest

· Sleep routines/hours of your community: Compare with sleep hour standards (from National Institutes of Health [NIH]).

· Indicators of general “restedness” and energy levels.

· Factors affecting sleep:

· Shift work prevalence of community members

· Environment (noise, lights, crowding, etc.)

· Consumption of caffeine, nicotine, alcohol, and drugs

· Homework/Extracurricular activities

· Health issues

Cognitive/Perceptual

· Primary language: Is this a communication barrier?

· Educational levels: For geopolitical communities, use http://www.census.gov and compare the city in which your community belongs with the national statistics.

· Opportunities/Programs:

· Educational offerings (in-services, continuing education, GED, etc.)

· Educational mandates (yearly in-services, continuing education, English learners, etc.)

· Special education programs (e.g., learning disabled, emotionally disabled, physically disabled, and gifted)

· Library or computer/Internet resources and usage.

· Funding resources (tuition reimbursement, scholarships, etc.).

Self-Perception/Self-Concept

· Age levels.

· Programs and activities related to community building (strengthening the community).

· Community history.

· Pride indicators: Self-esteem or caring behaviors.

· Published description (pamphlets, Web sites, etc.).

Role/Relationship

· Interaction of community members (e.g., friendliness, openness, bullying, prejudices, etc.).

· Vulnerable populations:

· Why are they vulnerable?

· How does this impact health?

· Power groups (church council, student council, administration, PTA, and gangs):

· How do they hold power?

· Positive or negative influence on community?

· Harassment policies/discrimination policies.

· Relationship with broader community:

· Police

· Fire/EMS (response time)

· Other (food drives, blood drives, missions, etc.)

Sexuality/Reproductive

· Relationships and behavior among community members.

· Educational offerings/programs (e.g., growth and development, STD/AIDS education, contraception, abstinence, etc.).

· Access to birth control.

· Birth rates, abortions, and miscarriages (if applicable).

· Access to maternal child health programs and services (crisis pregnancy center, support groups, prenatal care, maternity leave, etc.).

Coping/Stress

· Delinquency/violence issues.

· Crime issues/indicators.

· Poverty issues/indicators.

· CPS or APS abuse referrals: Compare with previous years.

· Drug abuse rates, alcohol use, and abuse: Compare with previous years.

· Stressors.

· Stress management resources (e.g., hotlines, support groups, etc.).

· Prevalent mental health issues/concerns:

· How does the community deal with mental health issues

· Mental health professionals within community and usage

· Disaster planning:

· Past disasters

· Drills (what, how often)

· Planning committee (members, roles)

· Policies

· Crisis intervention plan