Fill and Sign the Preferred Risk Policy Fema Form

CRA Exercise 2008-2009 Tier Group Screening Form Screening Questions 1. Complete each of the following questions: How old are you? What is your health status? (Mark 1 box only) 6 mo-35 mo 3 yr-18 yr 19 yr-64 yr 65 or older (Mark all that apply) Pregnant High risk med condition** Healthy Do you live in a household with an infant less than 6 months old? (Mark 1 box only) Yes No ** High Risk Medical Condition: Chronic lung disease (including asthma); Heart disease (excluding high blood pressure); Kidney disease; Liver disease; Diabetes; Blood disorders; Brain, spinal cord or muscle illnesses that cause swallowing or lung problems; Problems with immune protection system caused by medications and/or HIV. Tier Group Classification 2. Select ONE tier group only. NOTE: When more than one tier group classification applies, use the highest priority tier group. Example: If a person is in age group “19-64”, is “pregnant” and has a “high risk medical condition”, use TIER Group 1. Reason: Pregnancy is in a higher tier group than either their age group or their high risk medical condition. Check one box only: Tier 1: Pregnant Infants and toddlers 6 mos-35 mo Tier 2: Household contacts of infants < 6 mo Children 3-18 yrs with high risk medical condition Tier 3: Children 3-18 yrs without high risk condition Tier 4: Persons 19-64 with high risk condition Persons >65 yrs old Tier 5: Healthy adults 19-64 yrs old 3. Enter the highest priority tier group on the record sheet for data entry. a) “Influenza Authorization Record—Aggregate Counts”; OR b) “Patient Level CRA Data Collection Form”