Page 1 of 1

Member Outreach Connection Data

Your Name

Outreach Date

Location/Address

First Name

Last Name

Is this person known to us?

Is this person known to us?
A
B

Gender

Gender
A
B

Is the person born in Australia?

Is the person born in Australia?
A
B

Aboriginal/Torres Strait Islander

Ethnicity

Date of Birth

Age

Mobile Phone Number

Email Address

What disease or health concerns did they present with or are known to have?

Do they have a chronic disease? Chronic disease is defined as having the same issue/sickness for more than 3 months

Is there chronic disease case managed/care coordinated by our service? For example, they are known to us and currently on our active member list?

Is there chronic disease case managed/care coordinated by our service? For example, they are known to us and currently on our active member list?
A
B

Did they see the Registered Nurse (RN) for any cares?

Did they see the Registered Nurse (RN) for any cares?
A
B

Was a HOH online referral completed?

Was a HOH online referral completed?
A
B

Were they referred to accomodation services?

Were they referred for follow-up support to health care providers?

Does the member have a disability pension?

Does the member have a disability pension?
A
B

Does the member/participant have a disability?

What services is the member engaged with?

What services is the member engaged with?

Please specify any key contacts at services they engage regularly with.