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Forms: Administrative Forms
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A Tool for Identifying Migrant and Seasonal Farmworkers in Your Clinic
MCN recommends screening for migrant status at every clinic visit. This bilingual tool is designed to help clinic staff identify migrant and seasonal farmworkers.
Files
- Id Migrant Seasonal Farmworkers Mcn Sp Eng.pdf( 373.00 Kb )
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5
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Algorithm for identification of migrant and seasonal farmworkers
This algorithm in English and Spanish can be used by health center program grantees as part of the intake process to identify farmworker patients. It incorporates HRSA’s 2012 revised definition of migrant and seasonal farmworkers.
Files
- Algorithm Id Msfw.pdf( 4,673.95 Kb )
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HRCH Pregnancy Pamphlet- Spanish
Usted y su bebe pregnancy pamplet.
Files
- Ud. Y Su Bebe-hrch Pregnancy Pamphlet.doc( 1,658.88 Kb )
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Incident Report Form
Two-page form used to report accidents or incidents in the clinic.
Files
- Incident Reportform.doc( 322.56 Kb )
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Sample Service Contract
THIS AGREEEMENT made effective the date of signing below, between ****** COMMUNITY HEALTH CENTER, INC., hereinafter referred to as “***,” and *****, hereinafter referred to as “****.”........
Files
- Tallgrass+agreement.doc( 552.96 Kb )
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Verbal/Telephone Orders and Test Results
To define a process for accepting verbal or telephone orders and test results directly from physicians, physician extenders (Physician Assistants, Nurse Midwives, Nurse Practitioners), labs and/or testing services.
Files
- 3.02.19 Verbal Orders And Critical Values2.doc( 312.32 Kb )
