1. KING COUNTY ASTMA PROGRAM Screening Questionnaires Checklists

2. PURPOSE  Eligibility Phone Screening: To determine if the potential participant is eligible for KCAP  Home Environment Checklist: Identify participant’s home triggers and participant behaviors related to triggers  Baseline: Capture basic health information related to asthma symptoms, asthma control, & medications

3. WHEN TO THEY HAPPEN?  Eligibility Phone Screening Two weeks after the provider letter is sent With in 24 hours of a self- referral via KCAP message line Warm Transfer from Ramona  HomeBASE HEC: within 2 weeks of eligibility screening Baseline: within 2 weeks of the HEC (GCRC)  Medicaid Home Visit HEC & Baseline: within 2 weeks of eligibility screening

4. INSTRUMENT FORMAT  Participant ID  Question number  Question  Answer Set  Response

5. PARTICIPANT IDENTIFICAITON NUMBER Participant ID______________  At the top of each page of the questionnaires is a participant identification number. This number will be on each page in the event a page is separated from the document.  The number is automatically assigned as a participant is enrolled into the program

6. QUESTION  Question #: the number of the question based on the section and the sequence. The question number is a combination of the section title initials and the order of the question. Sub questions will include a small case letter.

7. QUESTION NUMBER

8. ANSWER SET  Numeric This is where you will select the answer from a list of options and record the answer number in the response column.  Alpha This is where you will write in a response based on the participant’s answer.

9. CHW ACTION  Questions and Actions: the statement to be read, the question for the participant and the answer possibilities.  Interviewer statements are in Blue italic, actions are in Blue bold and the questions are in black bold.  HEC ONLY A – Ask the question O – Observe only A+O – Ask the question and observe

10. RESPONSE  Response: is a column located to the far right of the question to record the answer set number or a specified response such as the number of events in a day.  The response area is a blank line with the corresponding question number at the end of the blank line.

11. PARTICIPANT FILE TYPE DEMOGRAPHIC  Enrollment information Including all contact information and personal identifiers  Cover Sheets from ALL screenings and questionnaires  Randomization envelope  Map to participant's house  Home visit checklist  Any provider communications  Confirmation of gift cards and supplies INTERVENTION  HEC  Baseline Questionnaire  Eligibility Screening  All intervention education materials

12. ELIGIBILITY PHONE SCREENING  Face Sheet: complete with contact information  Introduction: Overview purpose and availability to take the call.  Questions: To determine eligibility & read all questions  Eligible:  Next Steps: Schedule home visit for both programs.

13. REVIEW-HEC  Face Sheet: Already complete with contact information  Introduction: Overview purpose of the checklist  Questions: To determine participant health behaviors and environmental triggers  Differences: between HomeBASE and Medicaid  Next Steps: Schedule Follow-up home visit MAP and GCRC visit for HomeBASE (HB)

14. BASELINE QUESTIONNAIRE  Face Sheet: Already complete with contact information  Introduction: Overview purpose of the questionnaire  Questions: To determine participant health and asthma symptoms and control.  Differences: between HomeBASE and Medicaid  Next Steps: Schedule home-visit

15. Questions  Phone Screening  HEC  Baseline