Form 3 Patient Navigator Survey

HRSA Patient Navigator Demonstration Program

Navigator Form (DRAFT)

Introduction to the Navigator Characteristics Form

These are draft instructions. Do not train staff with this document until drafts have been finalized.

Revisions may be made to improve form/data entry screen layout and the clarity of instructions.

A final version of this document will be released no later than May 2011.

Suggestions for improvements are welcome.

The Navigator Characteristics Form is a tool that may be used to facilitate collection of navigator demographic data. Data from all patient navigators participating in the program will need to be collected and reported to NOVA Research for inclusion in the data analysis. The data should be entered at the beginning of the navigator’s employment, and does not need to be updated over time.

After the data system is online, data for all study navigators should be entered into the system. Data may be recorded prior to the launch of the system for later entry, or may be entered directly into the system once launched. No further changes are expected on the Navigator Form, and since the data entry screen on the online system will mirror the attached form, sites should be able to use the paper form and the online screen interchangeably throughout the project, minimizing training needs.

Using the Navigator Characteristics Form. You are welcome to customize and otherwise modify the formatting of the Navigator Form. For example, you may choose to highlight options under required elements (categories) applicable to your site, or to delete those that are not applicable. However, you are responsible for the information on the form, so take care to avoid deleting required data elements. Since the data entry screen on the online database will mirror this data entry form, major changes are likely to cause increased data entry effort. If there is doubt about whether a specific modification may cause problems, please contact NOVA.

Navigator IDs. Each navigator should be assigned a unique numeric identifier. The valid range for navigation codes is 1-50. If a navigator leaves the program, his/her ID may not be recycled.

Please email any questions or concerns regarding these instructions or the form to Debra Stark dstark@novaresearch.com and Caroline McLeod cmcleod@novaresearch.com.

Navigator Characteristics Form (DRAFT)

Site use only: Local Identifier:	Navigator ID:
	Hire Date:

Demographics
Gender Male Female Transgender Birth year Birth year: __ __ __ __ 3-digit zip prefix zip: __ __ __	Ethnicity Hispanic or Latino Non-Hispanic Race Check all that apply White Black/African American Asian Native Hawaiian/Pacific Islander American Indian/Alaska Native Optional race coding:

Education

Check one

• No formal education

• Primary education only

• Some HS/secondary education

• HS Diploma/GED/other secondary education

• Some college/vocational school/other post-secondary education

• Completed college, post-secondary or vocational school

• Post-college/graduate school

Professional Education/Training

Check all that apply

• None

• RN

• LPN

• Medical Assistant/ Nurses Aide

• Social Worker

• Phlebotomist

• Radiology Technologist

• Mammography Technologist

• PN certification

• Community Health Worker (CHW) certification

• CHW training for specific condition

• Workshops/trainings

• Certified Medical Interpreter

• Alternative Health Care Provider

• Other (Specify: )

Primary Language

Check one

 English

 Spanish

 Chinese

 Fijian

 Filipino Tagalog

 Filipino Ilocano

 Filipino Visayan

 Filipino: Other

 French

 Haitian Creole

 Hmong

 Japanese

 Korean

 Micronesian: Chuukese

 Micronesian: Kosraean

 Micronesian: Marshalese

 Micronesian: Pohnpeian

 Micronesian: Yapese

 Mixteco

 Navajo

 Samoan

 Somali

 Tongan

 Vietnamese

 Other
(Specify: )

Notes:

Additional Language(s)

Check all that apply

 None

 English

 Spanish

 Chinese

 Fijian

 Filipino Tagalog

 Filipino Ilocano

 Filipino Visayan

 Filipino: Other

 French

 Haitian Creole

 Hmong

 Japanese

 Korean

 Micronesian: Chuukese

 Micronesian: Kosraean

 Micronesian: Marshalese

 Micronesian: Pohnpeian

 Micronesian: Yapese

 Mixteco

 Navajo

 Samoan

 Somali

 Tongan

 Vietnamese

 Other
(Specify: )

Site use only, additional notes:

Instructions for Completing the Navigator Characteristics Form (DRAFT)

These are draft instructions. Do not train staff with this document until drafts have been finalized.

Revisions may be made to improve form/data entry screen layout and the clarity of instructions.

A final version of this document will be released no later than May 2011.

Suggestions for improvements are welcome.

The data included on the Navigator Form should be collected every time a new navigator is hired.

Demographics

Local Identifier This item should be used to record whatever local identifier will be helpful to local staff; these data will not be entered into the study database.

Navigator ID Use this space to record the Navigator Identifier; this is the unique numeric ID assigned to each navigated patient. This may be left blank until procedures for assigning study IDs are in place.

Hire Date Record the date the navigator was brought on to the project. If the navigator was already on staff at grant initiation, enter the grant start date. If the navigator had previously been working on other projects, enter the date duties related to this project were initiated.

Demographics

Gender Record the navigator’s gender.

Birth year Record the navigator’s 4-digit year of birth.

Ethnicity Indicate whether or not the navigator identifies himself/herself as Hispanic/Latino.

Race Record the navigator’s race.

Optional race coding (Optional) Record additional race classifications that will be used for local analysis. The online system will include a space in which to enter these data. This field is not a required component of the cross-site evaluation.

Language

Primary Language Record the navigator’s primary or preferred language (e.g., the language the patient speaks at home). If Other is selected, please specify the other language spoken.

Additional Language(s) Check any additional languages spoken by the navigator. If Other is selected, please specify the other language(s) spoken by the navigator. Check the “None” box if the primary language is the only language spoken by the navigator.

Education

Education Record the highest level of education completed by the navigator. This should reflect the navigator’s education at the time they started work on the project and should not be updated even if their educational status changes.

Professional Education Record any professional education and/or training the navigator has completed. If Other is selected, please specify the other education/training that the navigator has completed. This should reflect the navigator’s education at the time they started work on the project and should not be updated even if their educational status changes.