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
Yes
B
No
Gender
*
Gender
A
Male
B
Female
Is the person born in Australia?
Is the person born in Australia?
A
Yes
B
No
Aboriginal/Torres Strait Islander
Ethnicity
Date of Birth
Age
URN (Unique Record Number)
This allows us to search medical history and ensure for accuracy if no Medicare Card is provided.
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
Yes
B
No
Did they see the Registered Nurse (RN) for any cares?
Did they see the Registered Nurse (RN) for any cares?
A
Yes
B
No
Was a HOH online referral completed?
*
Was a HOH online referral completed?
A
Yes
B
No
Were they referred to accommodation 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
Yes
B
No
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.
Submit