Please follow rubric and instructions i have attached.
arie33511
WindshieldSurveyTemplate7.docx
COMMUNITY ASSESSMENT REPORT FORM
Part 1: Windshield Survey
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Component: Windshield Survey – Boundaries |
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Assessment Click or tap here to enter text.
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Analysis Click or tap here to enter text.
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Component: Physical Characteristics |
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Assessment Findings
Community Existence: Click or tap here to enter text.
Demographic Data:Click or tap here to enter text.
How Does the Community Look:Click or tap here to enter text.
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Analysis Click or tap here to enter text.
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Component: Psychosocial Characteristics |
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Assessment Findings Religion: Click or tap here to enter text.
Health & Social Services: Click or tap here to enter text.
Economy: Click or tap here to enter text.
Transportation: Click or tap here to enter text.
Safety: Click or tap here to enter text.
Politics & Government: Click or tap here to enter text.
Communication / Media: Click or tap here to enter text.
Education: Click or tap here to enter text.
Recreation: Click or tap here to enter text.
Values:Click or tap here to enter text.
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Analysis Click or tap here to enter text.
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Part II: Community Data
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Component: Community Data (express results in %) |
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Live Births: Community/County |
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General Death |
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· Mortality (general) |
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· Infant |
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Heart Disease |
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Cancer |
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Stroke |
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Accidents |
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Diabetes |
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Suicide |
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AIDs |
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Morbidity |
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Tuberculosis |
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Syphilis |
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Gonorrhea |
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AIDS |
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Life Expectancy |
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Component: Census Data (% where indicated) |
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Population Count |
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Persons under 5 years (%) |
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Persons under 18 years (%) |
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Persons 65 years and over (%) |
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White alone (%) |
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Black or African American alone (%) |
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Asian alone (%) |
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Native Hawaiian and other Pacific Islander alone (%) |
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Two or More Races (%) |
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Hispanic or Latino (%) |
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Foreign Born Persons (%) |
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High School Graduate or Higher (age 25+) (%) |
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Language other than English spoken at home (%) |
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Bachelor’s degree or higher (%) |
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Veterans (%) |
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Median household income |
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Poverty (%) |
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Identify Vulnerable Populations & Identify 2 Potential Health Care Needs
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Vulnerable Population: Click or tap here to enter text.
Two health care needs: Click or tap here to enter text. |
Part III: Environmental Assessment
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Component: Environmental Assessment |
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Assessment
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Describe the Implications of: · Chemical exposure on health · Lead exposure on health · Poor Air quality on health · Unequal Distribution of Burden |
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Toxic Chemicals: · Top Polluter in County · Top Chemical Released in County
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Lead Hazards: · % of houses with high risk of lead | Click or tap here to enter text. |
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Air: · Top Polluter in County | Click or tap here to enter text. |
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Environmental Justice: (Environmental Justice Mapper) · Identify Unequal Distribution of Burdens by Race/Ethnicity | Click or tap here to enter text. |
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Part IV: Community Member Interviews
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Component: Community Member Interviews |
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Community Member 1 |
Community Member 2 |
Community Member 3 |
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Name: :Click or tap here to enter text. Position: :Click or tap here to enter text. Contact Information: Click or tap here to enter text.
Health/Illness Beliefs, Values, Attitudes and Practices Click or tap here to enter text.
Community Strengths Click or tap here to enter text.
Community Needs Click or tap here to enter text.
Level of Safety Click or tap here to enter text.
General Concerns Click or tap here to enter text.
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Name: Click or tap here to enter text. Position: Click or tap here to enter text. Contact Information: Click or tap here to enter text.
Health/Illness Beliefs, Values, Attitudes and Practices Click or tap here to enter text.
Community Strengths Click or tap here to enter text.
Community Needs Click or tap here to enter text.
Level of Safety Click or tap here to enter text.
General Concerns Click or tap here to enter text.
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Name: Click or tap here to enter text. Position: Click or tap here to enter text. Contact Information :Click or tap here to enter text.
Health/Illness Beliefs, Values, Attitudes and Practices Click or tap here to enter text.
Community Strengths Click or tap here to enter text.
Community Needs Click or tap here to enter text.
Level of Safety Click or tap here to enter text.
General Concerns Click or tap here to enter text.
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Summarize Findings Click or tap here to enter text.
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Part V: Collaboration
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Component: Collaboration with Community Healthcare Team Member |
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Community Health Member |
Top 3 Priority Needs |
Describe Target Population |
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Name:Click or tap here to enter text. Position:Click or tap here to enter text. Contact Information:Click or tap here to enter text. Phone:Click or tap here to enter text. Email: Click or tap here to enter text. |
1.Click or tap here to enter text. 2. Click or tap here to enter text. 3. Click or tap here to enter text. | Click or tap here to enter text. |
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1. Develop a community diagnosis. Use the correct format: Health Risk/problem/potential of/for (specific injury, illness, or potential of, complications of, etc.) among (specific population) related to (supporting evidence of risk factors) as evidenced by (contributing factors). Click or tap here to enter text.
2. Identify 1 possible solution to address targeted need. Click or tap here to enter text.
3. Identify 1 primary, secondary, or tertiary intervention strategy to address targeted need. Click or tap here to enter text.
4. Develop 1 expected outcome in the form of a measurable objective - delineate who, what, and when (outcome objective, process objective, management objectives). Click or tap here to enter text.
5. Delineate 2 evaluation strategies (to determine if the intervention was successful). Click or tap here to enter text.
6. Identify potential resources needed to address targeted need (list a minimum of 3). Click or tap here to enter text.
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NSG4210 - VERSION 1 - 6/7/17 (nab)
