What's the preferred language of the individual?
Kajin ta eo em̗m̗anl̗o̗k ippān armej eo n̄an an kōjerbale?
¿Cuál es su idioma de preferencia?
* must provide value
English
Marshallese
Spanish
English
Marshallese
Spanish
UAMS Maternal Child Health Programs support parents and families through education, healthcare connections, and personalized services at home, in hospitals, community settings, or over the phone.
Būrokraam̗ eo an Maternal Child Health ilo UAMS ej jipan̄ Mama & Baba ro im kajjojo baamle ko ilo wāwein katakin, lelok er n̄an jikin jipan̄ ikkijen taktō, im jipan̄ ko rej aikuji n̄an er make - emaron̄ ilo kapijuknen eo, ilo hospital ko, jukjukinpād, a kilo talboon barenwot.
UAMS Maternal Child Health Programs support parents and families through education, healthcare connections, and personalized services at home, in hospitals, community settings, or over the phone.
Los Programas de Salud Materno- Infantil de UAMS apoyan a padres y familias a través de la educación, conexiones a servicios de salud y otros servicios personalizados, ya sea en el hogar, en hospitales, en entornos comunitarios o por teléfono..
UAMS Maternal Child Health Programs support parents and families through education, healthcare connections, and personalized services at home, in hospitals, community settings, or over the phone.
Who is filling out this form?
I am filling out this form for myself
I am a UAMS Community Health Worker filling this out
I am filling this out for a patient/client
I am filling out this form for myself
I am a UAMS Community Health Worker filling this out
I am filling this out for a patient/client
Who is interested in the Maternal Child Health Program? Wōn ej itok limo ilo Būrookraam̗ eo ikijjien Ājmour an Ajiri eo im Jinen (Maternal Child Health Program)? ¿A quién le interesa el Programa de Salud Materno Infantil?
* must provide value
Mother/Stepmother/Adoptive Mother/Grandmother/Aunt/Guardian(Mama/Stepmother/Jinen ilo kokajiriri/Bubu im Jimma/Naj Jinen/ak rikejbaroke) (Madre/Madrastra/Madre Adoptiva/Abuela/Tía/Tutor)
Father/Stepfather/Adoptive Father/Grandfather/Uncle/Guardian(Baba/Stepfather/Jemen ilo kõkajiriri/Bubu im Jimma/Naj Jemen/ak rikejbaroke) (Padre/Padrastro/Padre Adoptivo/Abuelo/Tío/Tutor)
Other, please specify(Ko jet, jouj im kalikar ta) (Otro, por favor describa)
Mother/Stepmother/Adoptive Mother/Grandmother/Aunt/Guardian(Mama/Stepmother/Jinen ilo kokajiriri/Bubu im Jimma/Naj Jinen/ak rikejbaroke) (Madre/Madrastra/Madre Adoptiva/Abuela/Tía/Tutor)
Father/Stepfather/Adoptive Father/Grandfather/Uncle/Guardian(Baba/Stepfather/Jemen ilo kõkajiriri/Bubu im Jimma/Naj Jemen/ak rikejbaroke) (Padre/Padrastro/Padre Adoptivo/Abuelo/Tío/Tutor)
Other, please specify(Ko jet, jouj im kalikar ta) (Otro, por favor describa)
Other, please specify Ko jet, jouj im kalikar ta Otro, por favor describa
What is the HOUSEHOLD'S preferred language? Kajin ta eo ro ilo MWEO rej konan kojerbale? ¿Cuál es el idioma preferido en el HOGAR?
English(Belle) (Ingles)
Marshallese(Majōl) (Marshalés)
Spanish(Spanish) (Español)
Other, please specify: (Ko jet, jouj im kalikar ta) (Otro, por favor describa)
English(Belle) (Ingles)
Marshallese(Majōl) (Marshalés)
Spanish(Spanish) (Español)
Other, please specify: (Ko jet, jouj im kalikar ta) (Otro, por favor describa)
Other, please specify Ko jet, jouj im kalikar ta Otro, por favor describa
Are you filling out this form for yourself, your partner, or are you referring a patient/client? Kwoj kanne pepa in nan kwe, eo riturum, ke juon rinaninmij/client eo im kwoj boktok ie? ¿Está usted completando este formulario para usted, su pareja o está refiriendo a un paciente/cliente?
I am filling out for a patient/client(N̄aij kanne n̄an rinan̄inmij/client) (Estoy llenándolo para un paciente/cliente)
I am filling this form out for myself(N̄aij kanne pepa in n̄an n̄a) (Estoy completando esta formulario para mí mismo)
I am a UAMS Community Health Worker filling this out(N̄aij kanne einwōt juōn UAMS Community Health Worker) (Soy un trabajador de salud de la comunidad de UAMS llenando este formulario)
I am filling this form out for my partner(N̄aij kanne pepa in n̄an eo rituru) (Estoy completando este formulario para mi pareja)
I am filling out for a patient/client(N̄aij kanne n̄an rinan̄inmij/client) (Estoy llenándolo para un paciente/cliente)
I am filling this form out for myself(N̄aij kanne pepa in n̄an n̄a) (Estoy completando esta formulario para mí mismo)
I am a UAMS Community Health Worker filling this out(N̄aij kanne einwōt juōn UAMS Community Health Worker) (Soy un trabajador de salud de la comunidad de UAMS llenando este formulario)
I am filling this form out for my partner(N̄aij kanne pepa in n̄an eo rituru) (Estoy completando este formulario para mi pareja)
I consent to have my information provided to UAMS to be contacted for the Maternal Child Health Program. Ij kōmalim bwe melele ko aō emōj lelak ńan UAMS ren maroń in jerbal ńan burokram eo an Maternal Child Health Program. Doy permiso que mi información sea compartida con UAMS y estar en comunicación continuamente como parte del programa de Maternal Child Health Program.
* must provide value
Which Community Health Worker? Ewi ian Community Health Worker rã? ¿Cuál trabajador(a) comunitario de Salud?
Which Community Health Worker? Ewi ian Community Health Worker rã? ¿Cuál trabajador(a) comunitario de Salud?
Mell
Carolina
Maryann
Litha
Ani
Albina
Joeleen
Marisela
Emily
Mandy S.
Amy R.
Frailan R.
Likey I.
Grace J.
Yolani E.
Lauren P.
Lisette C.
Claudia G.
Emri L.
Donald S.
Fernando R.
Oscar M.
Other
Mell
Carolina
Maryann
Litha
Ani
Albina
Joeleen
Marisela
Emily
Mandy S.
Amy R.
Frailan R.
Likey I.
Grace J.
Yolani E.
Lauren P.
Lisette C.
Claudia G.
Emri L.
Donald S.
Fernando R.
Oscar M.
Other
Other UAMS Staff Name: Etan staff rã jet an UAMS: Nombre de otro personal de UAMS:
Client Partner's Name Etan Partner eo an Client eo Nombre de la Pareja del Cliente
M-D-Y
What is your partner's date of birth? Raan in lotak eo an eo riturum? ¿Cuál es la fecha de Nacimiento de su pareja?
M-D-Y
Are you currently pregnant, or is someone in your household pregnant?
* must provide value
Yes
No
Do you have an established medical provider?
Yes
No
Are you interested in connecting to prenatal care in your community?
Yes
No
What is the MOTHER'S due date?
M-D-Y
Do you have children? Ewor ke ajiri ibbam? ¿Tiene usted hijos?
Yes(Aet) (Si)
No(Jaab) (No)
Are you the child(ren)'s primary caregiver? Kwe ne kwoj lale ajiri ne/rane? ¿Es usted la persona que cuida principalmente de los niños?
Yes(Aet) (Si)
No(Jaab) (No)
Do you have any children who are 24 years old or younger? Please include biological children, adopted children, stepchildren, foster children, and any child or youth up to age 24 whom you are actively raising and who is the child of a partner or relative but who is not your biological or legally adopted child. Ewōr ke nejūm ajiri 24 iiō ak diklok? Jouj im kobaik ajiri ro lukkun nejūm, kōkajiriri, nejūn kōrā eo ibbam, ajiri jen foster care eo, im aolep ajiri ak jodikdik ro rej 24 iio kwōj lale er im nejūn eo mōttam ak nukum ak ejjab lukkun nejūm ak ejjelok am pepa in (legally) kajiririki. ¿Tiene algún hijo(a) de 24 años o menos? Por favor incluya a sus hijos biológicos, hijos adoptados, hijastros, niños en acogida, y cualquier hijo(a) o joven de hasta 24 años que está criando activamente y que es hijo(a) de su pareja o familiar pero que no es su hijo(a) biológico(a) ni legalmente adoptado(a).
Yes(Aet) (Si)
No(Jaab) (No)
Are any of your children younger than 17 months? Ewor ke ian ajiri rane edriklok jen 17 ann allõñ? ¿Alguno de sus hijos es menor de 17 meses?
Yes(Aet) (Si)
No(Jaab) (No)
What is the child's date of birth? Raan in l̗otak an ajiri eo? ¿Fecha de nacimiento del niño?
Today M-D-Y
Our parenting curriculum is used to improve the knowledge, behavior, and skills of dads, moms and parental figures. The curriculum helps parents reflect on how they were raised affects their relationship with their children and each other. Our parenting education includes 12 total lessons, which last up to 2 hours in duration. These lessons are taught weekly in-person or virtually. We offer classes for mothers only, fathers only and a couples class.
Laajrak in katakin in am kōn kilen juon jinen im jemān juon baam̗le ej jerbal n̄an kōkōm̗anm̗anl̗o̗k jel̗ā eo, m̗wil, im kapeel ko an baba ro, m̗am̗a ro im ro rej bōk jerbal in jinen ak jemān juon baam̗le. Curriculum ak laajrak in katakin in ejipan̄ m̗am̗a im baba ro ilo aer l̗ōmn̗ake l̗o̗k ewi wāwein an jineir im jemāer kar lale er jelōt kōtaan ko aer ippān ajiri ro nejier im er n̄an doon. Parenting education in am n̄an katakin kilen am̗ juon jinen ak juon jemān juon baam̗le ekitbuuj 12 aolepen kein ekkatak ko ie im lōn̄l̗o̗k n̄an 2 awa aetokeir. Kein ekkatak kein rej kōm̗m̗an kajjojo wiik ilo armej ak ilo online. Kemij kōm̗m̗an kilaaj ko n̄an m̗am̗a ro wōt, baba ro wōt, im juon kilaaj n̄an ripālele ro.
Nuestro currículo es usado para mejorar el conocimiento, comportamiento, y habilidades de los padres, madres, y figuras paternas. El currículo ayuda a los padres a reflexionar en la manera como ellos fueron criados y como esto afecta la relación que tengan con sus hijos y con sus parejas. Nuestra educación paterna incluye 12 clases en total, con una duración de hasta 2 horas. Estas clases son semanales, y se enseñan virtualmente o en persona. Contamos con clases destinadas solo para madres, padres, y una clase para parejas.
Are you currently involved with another home visiting program? Kwōj ke kiō bōk kwon̗aam̗ ippān bar juon būrookraam̗ rej lo waj kwe ilo kapijukunen eo am̗? ¿Participa actualmente en otro programa de visitas a domicilio?
Yes(Aet) (Si)
No(Jaab) (No)
The option "
Are you interested in parenting education classes? SELECT ALL THAT APPLY Kwōj ke itok limo ilo kilaaj ko ikijjien katak parenting ak katak kilen juon m̗am̗a ak juon baba? KĀLET AOLEP ME REKKAR Está interesada en clases educativas para padres? ESCOJA LAS RESPUESTAS QUE APLICAN
What is the BEST way to contact you? Waween ta eo EMMAN TATA n̄an tōbar eok? ¿Cuál es la MEJOR manera de contactarlo?
Phone call(Call eok) (Por teléfono)
Email(Email eok) (Correo Electrónico)
Texting(Jeje waj ilo talboon) (Mensaje de Texto)
Facebook Messenger(Message ak inbox waj ilo FB) (Messenger en Facebook)
Other(Ko jet) (Otro método)
Phone call(Call eok) (Por teléfono)
Email(Email eok) (Correo Electrónico)
Texting(Jeje waj ilo talboon) (Mensaje de Texto)
Facebook Messenger(Message ak inbox waj ilo FB) (Messenger en Facebook)
Other(Ko jet) (Otro método)
What is the BEST way to contact you?
What other method(s) of contact we should use to contact you? El̗ōn̄ ke bar waween ko remman n̄an tōbar eok? ¿Que otros métodos podríamos usar para contactarle?
If we can't reach you, can we leave you a voicemail?
Yes
No
If we can't reach you, can we leave you a voicemail?
Yes
No
Facebook (Messenger) Name
What is the BEST way to contact your PARTNER? Waween ta eo EMMAN TATA n̄an tōbar eo RITURUM? ¿Cuál es la MEJOR manera para contactar a su PAREJA?
Phone call(Call je) (Por teléfono)
Email(Email je) (Correo Electrónico)
Texting(Jeje lok ilo talboon) (Mensaje de Texto)
Facebook Messenger(Message ak inbox ie ilo FB) (Messenger en Facebook)
Other(Ko jet) (Otro método)
Phone call(Call je) (Por teléfono)
Email(Email je) (Correo Electrónico)
Texting(Jeje lok ilo talboon) (Mensaje de Texto)
Facebook Messenger(Message ak inbox ie ilo FB) (Messenger en Facebook)
Other(Ko jet) (Otro método)
What other method(s) of contact we should use to contact your PARTNER? El̗ōn̄ ke bar waween ko remman n̄an tōbar eo RITURUM? ¿Que otros métodos de contacto deberíamos usar para contactar a su PAREJA?
PARTNER'S Phone Number Talboon (PARTNER) Número de teléfono
Other Phone Number Talboon (Other) Otro número de teléfono
PARTNER'S Email Address Email address eo an KAREJARAM Correo Electrónico de su PAREJA
PARTNER'S Facebook (Messenger) Name Etan Faceback (Messenger) eo an KAREJARAM Nombre en Facebook (Messenger) de su PAREJA
Other, please specify Ko jet, jouj im kalikar ta Otro, por favor describa
County You Reside In Bukōn eo kwōj jokwe ie ¿En qué Condado reside?
* must provide value
Benton Washington Carroll Madison Other
Benton Washington Carroll Madison Arkansas County Ashley County Baxter County Boone County Bradley County Calhoun County Chicot County Clark County Clay County Cleburne County Cleveland County Columbia County Conway County Craighead County Crawford County Crittenden County Cross County Dallas County Desha County Drew County Faulkner County Franklin County Fulton County Garland County Grant County Greene County Hempstead County Hot Spring County Howard County Independence County Izard County Jackson County Jefferson County Johnson County Lafayette County Lawrence County Lee County Lincoln County Little River County Logan County Lonoke County Marion County Miller County Mississippi County Monroe County Montgomery County Nevada County Newton County Ouachita County Perry County Phillips County Pike County Poinsett County Polk County Pope County Prairie County Pulaski County Randolph County Saline County Scott County Searcy County Sebastian County Sevier County Sharp County St. Francis County Stone County Union County Van Buren County White County Woodruff County Yell County
In what other county do you reside?
PARTNER'S Street Address Atõrej eo an KAREJARAM Dirección de su PAREJA
PARTNER'S City where they reside City eo KAREJARAM ej jokwe ie Ciudad donde reside su PAREJA
County PARTNER Resides In County ak bukon ta eo KAREJARAM ej jokwe ie Condado donde reside su PAREJA
Benton Washington Carroll Madison Other
In what other county does your PARTNER reside? Couny ak bukon ta eo juon KAREJARAM ej jokwe ie? ¿En que otro condado reside su pareja?
How did you hear about us?
* must provide value
Someone referred me (Community health worker, friend, or family member)
Flyer or Advertisement
Flyer or Brochure
Social Media
Community Organization
Doctor's Office or Clinic
Health Department or Local Health Unit
Event
Church or place of worship
Community business
Word of mouth (friends, family, acquaintances)(Ron̄ nu ial (jen ro m̗ōtta, bamle, ro ijel̗ā kajeer)) (Palabra de boca en boca (amigos, familia, conocidos))
Newspaper ad, billboards, or a flyer(Newspepa, billboard, ak kōjjel̗ā ko) (Anuncio de periódico, cartelera, o un volante)
Radio ad or a TV spot(Radio ak TV) (Anuncio de radio o de televisión)
Internet ad or social media such as Facebook or Twitter(Ijoko ilo internet einwōt Facebook ak Twitter) (Por internet o red social, como Facebook o Twitter)
Community organization, such as a school, hospital, maternity clinic, doctor's office, place of worship, Head Start or Healthy Start center(Droulul ko ilo jukjukin bed eo, einwōt ilo jikuul, hospital, clinic ko an kōrā, opiij in taktō ko, mōn jar, Head Start an Healthy Start center) (Alguna organización en la comunidad, como una escuela, hospital, clínica de maternidad, oficina de un doctor, iglesia donde se congrega, centro de Head Start de un centro de Healthy Start)
Program staff or event(Rijerbal ro an burokraam eo ak ijoko jej ain dron ie) (Personal del programa o evento)
Church(Mon jar) (Iglesia)
In the community(Jukjuk in bed eo) (En la comunidad)
UAMS
HerHealth Clinic
Parkhill Clinic
Community Clinic
Northwest Health
Willowcreek
Creekside
Washington County Health Department
Arkansas Children's Hospital
Washington Regional
Marshallese Education Initiative (MEI)
Arkansas Coalition of Marshallese (ACOM)
Other, please specify
Someone referred me (Community health worker, friend, or family member)
Flyer or Advertisement
Flyer or Brochure
Social Media
Community Organization
Doctor's Office or Clinic
Health Department or Local Health Unit
Event
Church or place of worship
Community business
Word of mouth (friends, family, acquaintances)(Ron̄ nu ial (jen ro m̗ōtta, bamle, ro ijel̗ā kajeer)) (Palabra de boca en boca (amigos, familia, conocidos))
Newspaper ad, billboards, or a flyer(Newspepa, billboard, ak kōjjel̗ā ko) (Anuncio de periódico, cartelera, o un volante)
Radio ad or a TV spot(Radio ak TV) (Anuncio de radio o de televisión)
Internet ad or social media such as Facebook or Twitter(Ijoko ilo internet einwōt Facebook ak Twitter) (Por internet o red social, como Facebook o Twitter)
Community organization, such as a school, hospital, maternity clinic, doctor's office, place of worship, Head Start or Healthy Start center(Droulul ko ilo jukjukin bed eo, einwōt ilo jikuul, hospital, clinic ko an kōrā, opiij in taktō ko, mōn jar, Head Start an Healthy Start center) (Alguna organización en la comunidad, como una escuela, hospital, clínica de maternidad, oficina de un doctor, iglesia donde se congrega, centro de Head Start de un centro de Healthy Start)
Program staff or event(Rijerbal ro an burokraam eo ak ijoko jej ain dron ie) (Personal del programa o evento)
Church(Mon jar) (Iglesia)
In the community(Jukjuk in bed eo) (En la comunidad)
UAMS
HerHealth Clinic
Parkhill Clinic
Community Clinic
Northwest Health
Willowcreek
Creekside
Washington County Health Department
Arkansas Children's Hospital
Washington Regional
Marshallese Education Initiative (MEI)
Arkansas Coalition of Marshallese (ACOM)
Other, please specify
What church did you hear about us from?
How else did you hear about us?
Anything else we need to know to help connect you to services?
Wōn eo ej kadedelok men in?
N̄aij kanne pepa in n̄an n̄a
N̄aij kanne einwōt juōn UAMS Community Health Worker
N̄aij kanne n̄an rinan̄inmij/client
N̄aij kanne pepa in n̄an n̄a
N̄aij kanne einwōt juōn UAMS Community Health Worker
N̄aij kanne n̄an rinan̄inmij/client
Raan in lotak eo am?
* must provide value
M-D-Y
Kwōj ke juōn ribororo kio, ak el̗on̄ ke ebororo ilo mweo?
* must provide value
Aet
Jaab
Ewōr ke juon am̗ taktō em̗ōj am̗ jino taktō ippān?
Aet
Jaab
Are you interested in connecting to prenatal care in your community?
Yes
No
Ñaat eo MAMA ak RIBORORO eo enej kemmour?
M-D-Y
Waween ta eo EMMAN TATA n̄an tōbar eok? BEST way to contact you?
Ko jet, jouj im kalikar ta
El̗an̄n̄e kōmij jab maron̄ tōpar eok, jemaron̄ ke illik am̗ voicemail?
Aet Yes
Jaab No
Email address eo am
Talboon (Other)
El̗an̄n̄e kōmij jab maron̄ tōpar eok, jemaron̄ ke illik am̗ voicemail?
Aet Yes
Jaab No
Etam̗ ilo Facebook?
City ak ijo kwōj jokwe ie
* must provide value
Bukōn eo kwōj jokwe ie
* must provide value
Benton Washington Carroll Madison Arkansas County Ashley County Baxter County Boone County Bradley County Calhoun County Chicot County Clark County Clay County Cleburne County Cleveland County Columbia County Conway County Craighead County Crawford County Crittenden County Cross County Dallas County Desha County Drew County Faulkner County Franklin County Fulton County Garland County Grant County Greene County Hempstead County Hot Spring County Howard County Independence County Izard County Jackson County Jefferson County Johnson County Lafayette County Lawrence County Lee County Lincoln County Little River County Logan County Lonoke County Marion County Miller County Mississippi County Monroe County Montgomery County Nevada County Newton County Ouachita County Perry County Phillips County Pike County Poinsett County Polk County Pope County Prairie County Pulaski County Randolph County Saline County Scott County Searcy County Sebastian County Sevier County Sharp County St. Francis County Stone County Union County Van Buren County White County Woodruff County Yell County
County ak bukon ta ne juon kwoj bar jokwe ie?
Elemen am kar ron̄ kōn kem?
* must provide value
Bar juon armej ekar lel̗o̗k eta (Community health worker, m̗ōtta, ak nuku).
Peba in Kōjjeḷā ak Karreelel
pepa in kadelel ak melele ko ilo pepa eo.
Jikin iaron̄ron̄ ko ilo mejatoto ak online (Social Media)
Doulul an Jukjukunpād
Opiij an Taktō eo ak M̗wōn Taktō eo
Public Health eo el̗ap ak ilo bukwōn eo ijin
Juon iien el̗ap (Event)
M̗wōn Jar ak jikin kabun̄
Peejnej an Jukjukunpād
(Ron̄ nu ial (jen ro m̗ōtta, bamle, ro ijel̗ā kajeer))
(Newspepa, billboard, ak kōjjel̗ā ko)
(Radio ak TV)
(Ijoko ilo internet einwōt Facebook ak Twitter)
(Droulul ko ilo jukjukin bed eo, einwōt ilo jikuul, hospital, clinic ko an kōrā, opiij in taktō ko, mōn jar, Head Start an Healthy Start center)
(Rijerbal ro an burokraam eo ak ijoko jej ain dron ie)
(Mon jar)
(Jukjuk in bed eo)
UAMS
HerHealth Clinic
Parkhill Clinic
Community Clinic
Northwest Health
Willowcreek
Creekside
Washington County Health Department
Arkansas Children's Hospital
Washington Regional
Marshallese Education Initiative (MEI)
Arkansas Coalition of Marshallese (ACOM)
Bar juon wāwein ak jikin
Bar juon armej ekar lel̗o̗k eta (Community health worker, m̗ōtta, ak nuku).
Peba in Kōjjeḷā ak Karreelel
pepa in kadelel ak melele ko ilo pepa eo.
Jikin iaron̄ron̄ ko ilo mejatoto ak online (Social Media)
Doulul an Jukjukunpād
Opiij an Taktō eo ak M̗wōn Taktō eo
Public Health eo el̗ap ak ilo bukwōn eo ijin
Juon iien el̗ap (Event)
M̗wōn Jar ak jikin kabun̄
Peejnej an Jukjukunpād
(Ron̄ nu ial (jen ro m̗ōtta, bamle, ro ijel̗ā kajeer))
(Newspepa, billboard, ak kōjjel̗ā ko)
(Radio ak TV)
(Ijoko ilo internet einwōt Facebook ak Twitter)
(Droulul ko ilo jukjukin bed eo, einwōt ilo jikuul, hospital, clinic ko an kōrā, opiij in taktō ko, mōn jar, Head Start an Healthy Start center)
(Rijerbal ro an burokraam eo ak ijoko jej ain dron ie)
(Mon jar)
(Jukjuk in bed eo)
UAMS
HerHealth Clinic
Parkhill Clinic
Community Clinic
Northwest Health
Willowcreek
Creekside
Washington County Health Department
Arkansas Children's Hospital
Washington Regional
Marshallese Education Initiative (MEI)
Arkansas Coalition of Marshallese (ACOM)
Bar juon wāwein ak jikin
Mõn jar ta eo ear kenaanik eok kõn kem?
Ewi bar wãwein am kar roñ kõn kem?
Ewor ke men kem aikuj jela kake non jiban lelok yuk non menin jiban ko?
¿Quién está completando esto?
Estoy completando esta formulario para mí mismo
Soy un trabajador de salud de la comunidad de UAMS llenando este formulario
Estoy llenándolo para un paciente/cliente
Estoy completando esta formulario para mí mismo
Soy un trabajador de salud de la comunidad de UAMS llenando este formulario
Estoy llenándolo para un paciente/cliente
Fecha de nacimiento
Date of birth
* must provide value
M-D-Y
¿Está usted embarazada o alguien en su casa está embarazada?
Are you currently pregnant, or is someone in your household pregnant?
* must provide value
Si
No
¿Tiene un doctor o proveedor médico establecido?
Do you have an established medical provider?
Si
No
Are you interested in connecting to prenatal care in your community?
Si
No
La fecha de parto
What is the MOTHER'S due date?
M-D-Y
¿Cuál es la MEJOR manera de contactarlo?
What is the BEST way to contact you?
Otro, por favor describa
Other, please specify
Número de teléfono
Your Phone Number
Si no podemos comunicarnos con usted, ¿podemos dejarle un mensaje de voz?
Si Yes
No No
¿Cuál es su correo electrónico?
Your Email Address
Otro número de teléfono
Other Phone Number
Si no podemos comunicarnos con usted, ¿podemos dejarle un mensaje de voz?
Si Yes
No No
¿Cuál es su nombre en su Perfil de Facebook?
Facebook (Messenger) Name
¿Cuál es su dirección?
Your Street Address
Ciudad donde usted reside
City where you reside
* must provide value
¿En qué Condado reside?
County You Reside In
* must provide value
Benton Washington Carroll Madison Arkansas County Ashley County Baxter County Boone County Bradley County Calhoun County Chicot County Clark County Clay County Cleburne County Cleveland County Columbia County Conway County Craighead County Crawford County Crittenden County Cross County Dallas County Desha County Drew County Faulkner County Franklin County Fulton County Garland County Grant County Greene County Hempstead County Hot Spring County Howard County Independence County Izard County Jackson County Jefferson County Johnson County Lafayette County Lawrence County Lee County Lincoln County Little River County Logan County Lonoke County Marion County Miller County Mississippi County Monroe County Montgomery County Nevada County Newton County Ouachita County Perry County Phillips County Pike County Poinsett County Polk County Pope County Prairie County Pulaski County Randolph County Saline County Scott County Searcy County Sebastian County Sevier County Sharp County St. Francis County Stone County Union County Van Buren County White County Woodruff County Yell County
¿En que otro condado reside usted?
In what other county do you reside?
¿Como se enteró de nosotros?
How did you hear about us?
* must provide value
Alguien me recomendó (trabajador de salud comunitaria, amigo o familiar)
Folleto o anuncio
Volante o folleto
Redes sociales
Organización comunitaria
Clínica o consultorio médico
Departamento de Salud o Centro de Salud Local
Evento
Iglesia o lugar de adoración
Negocio local
(Palabra de boca en boca (amigos, familia, conocidos))
(Anuncio de periódico, cartelera, o un volante)
(Anuncio de radio o de televisión)
(Por internet o red social, como Facebook o Twitter)
(Alguna organización en la comunidad, como una escuela, hospital, clínica de maternidad, oficina de un doctor, iglesia donde se congrega, centro de Head Start de un centro de Healthy Start)
(Personal del programa o evento)
(Iglesia)
(En la comunidad)
UAMS
HerHealth Clinic
Parkhill Clinic
Community Clinic
Northwest Health
Willowcreek
Creekside
Washington County Health Department
Arkansas Children's Hospital
Washington Regional
Marshallese Education Initiative (MEI)
Arkansas Coalition of Marshallese (ACOM)
Otro
Alguien me recomendó (trabajador de salud comunitaria, amigo o familiar)
Folleto o anuncio
Volante o folleto
Redes sociales
Organización comunitaria
Clínica o consultorio médico
Departamento de Salud o Centro de Salud Local
Evento
Iglesia o lugar de adoración
Negocio local
(Palabra de boca en boca (amigos, familia, conocidos))
(Anuncio de periódico, cartelera, o un volante)
(Anuncio de radio o de televisión)
(Por internet o red social, como Facebook o Twitter)
(Alguna organización en la comunidad, como una escuela, hospital, clínica de maternidad, oficina de un doctor, iglesia donde se congrega, centro de Head Start de un centro de Healthy Start)
(Personal del programa o evento)
(Iglesia)
(En la comunidad)
UAMS
HerHealth Clinic
Parkhill Clinic
Community Clinic
Northwest Health
Willowcreek
Creekside
Washington County Health Department
Arkansas Children's Hospital
Washington Regional
Marshallese Education Initiative (MEI)
Arkansas Coalition of Marshallese (ACOM)
Otro
¿En qué iglesia escucho sobre nosotros?
What church did you hear about us from?
¿De qué otra manera se enteró sobre nosotros?
How else did you hear about us?
¿Algo más que necesitemos saber para ayudarle a conectar con los servicios?
ACWIH HOME VISIT REQUEST
HOME VISIT REQUIRED FOR THIS PARTICIPANT
Which program is the respondent assigned to?
RETIRED DO NOT USE Claudia (Healthy Start)
RETIRED DO NOT USE Victoria (Centering Pregnancy)
RETIRED DO NOT USE Peter/Donald (Fatherhood FIRE)
RETIRED DO NOT USE Shaun (Mobile Health)
RETIRED DO NOT USE Other
Healthy Start North (Ursula)
Healthy Start North (Claudia)
Healthy Start South (Andrea)
Healthy Start East (Morgan)
Mobile Health/Women's Health/Centering: North, South & East (Victoria)
RETIRED DO NOT USE Claudia (Healthy Start)
RETIRED DO NOT USE Victoria (Centering Pregnancy)
RETIRED DO NOT USE Peter/Donald (Fatherhood FIRE)
RETIRED DO NOT USE Shaun (Mobile Health)
RETIRED DO NOT USE Other
Healthy Start North (Ursula)
Healthy Start North (Claudia)
Healthy Start South (Andrea)
Healthy Start East (Morgan)
Mobile Health/Women's Health/Centering: North, South & East (Victoria)
View equation
Which Care Coordinator is assigned to reach out to this potential client?
Mell
Carolina
Maryann
Litha
Ani
Albina
Joeleen
Marisela
Emily
Mandy S.
Amy R.
Frailan
Likey I.
Grace J.
Yolani E.
Lauren P.
Lisette C.
Claudia G.
Desiree J.
Alissa S.
Emri L.
Claudia B.
Christina C.
Merely M.
Dorcas
Fernando R.
Oscar M.
Donald S.
Moises M.
Patrick B.
Other
Mell
Carolina
Maryann
Litha
Ani
Albina
Joeleen
Marisela
Emily
Mandy S.
Amy R.
Frailan
Likey I.
Grace J.
Yolani E.
Lauren P.
Lisette C.
Claudia G.
Desiree J.
Alissa S.
Emri L.
Claudia B.
Christina C.
Merely M.
Dorcas
Fernando R.
Oscar M.
Donald S.
Moises M.
Patrick B.
Other
Today M-D-Y
How many attempted contacts have been made?
1 Contact 2 Contacts 3 Contacts 4 Contacts 5 Contacts
Not Enrolled Enrolled in Healthy Start Enrolled in Fatherhood FIRE Enrolled with Community Health Worker Enrolled with Centering Pregnancy Other
Partner Enrollment Status
Not Enrolled Enrolled in Healthy Start Enrolled in Fatherhood FIRE Enrolled with Community Health Worker Enrolled with Centering Pregnancy Other
Has the client been entered into WFS?
Yes
No