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►5 <br /> Information Flow Assessment Questionnaire <br /> C. HEALTH INFORMATION SOURCES <br /> Identify agencieafaouree(s)that send or receive heats infonmadon to/ham your wodrgroup.Identify wheihersuch <br /> transmissions are on paper,electronic,fax or phone by placing a check mark(-1)in the appropriate columns. You may <br /> check more than one option for each source. If none apply,leave the column blank. <br /> SOURCES Send Receive I Paper I Electronic E Fax Phone <br /> In anent Facilities ' <br /> General Hospitals <br /> Rehabilitation Centers <br /> Nursing Homes <br /> VA Hospitals <br /> Psych iatric Hospitals <br /> Special Care Centers <br /> MR Centers <br /> Other(Specify <br /> Residential.Facilities <br /> Alternative Family Livin <br /> Apartment Living <br /> Assisted Living <br /> Family Care HometGroue Home <br /> Su rvised Living <br /> Train School <br /> Other S <br /> Education Facilities <br /> Governor Morehead School <br /> Public or Private Schools <br /> School for Deaf/Hard of Hearing <br /> Wright or Whitaker School <br /> Other(Specify <br /> OutpatientlDay Services <br /> Adult Day Care <br /> Child Day Care <br /> Community Clinics <br /> Developmental Evaluation Centers <br /> Em lo ee Assistance Program <br /> Hospital Ou tient <br /> Metal Huth Center/Area Program <br /> Public Health Dept <br /> Rehab Centers <br /> Sheltered Worksho <br /> Urgent Care Cater <br /> Other(SRM <br /> Social Services <br /> Child Fatality Prevention System <br /> Child Fatality Task Force <br /> Child Support Enforcement <br /> Child/Adult Protection Services <br /> Dept of Social Services <br /> Foster Home <br /> Other Spec <br /> July 2001-version 4 HIPAA 11 <br />