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Information Flaw Assessment QuesSonnaire b + <br /> A. INFORMATION CREATED,RECEIVED,SENT AND/OR STORED <br /> Identity those items that contain health informadon,which you currently create,receive,send and/or store in your <br /> area. If your workgroup does not create. receive,send and/or store health information than select none and continue to the <br /> next section,^.. <br /> Check(✓)all options that apply for each column. If description or option that applies to your workgroup is not listed <br /> under a category to the description listing in the blank line at the end of each category table. <br /> Storage is defined as health intormation retained in your work area for more than 30 days, <br /> To complete the Storece information columns.use one or aAof the toilowing options as aoproodaW <br /> •Under the Type column use O for Original and C thr Copy. <br /> •Under the Format column use P forpaper and E for electronic. <br /> •Under the How Stored column use the Storage fist on page.15 to list the appropriate number(s), <br /> 1.Administrative <br /> Storage <br /> Information Description Create Receive Send Store Typ e Format I Now Stored <br /> O C P E Use list <br /> Accident R2Mrtsjrpr client <br /> Application for Admission <br /> Cancer Registry <br /> Certificates Birth,Death,Other <br /> Complaint Information <br /> Correspondence,Memos Internal&External <br /> Criminal Background Checks <br /> Incident Reports <br /> Investigative Reports Abuse,Ne loot,Other <br /> Leaai Papers CommitmenUCustod /CourtlOther <br /> Logs Clients,Notes,Correspondence,Other) <br /> Meeting MinuteslNotes <br /> Photographs <br /> Questionnai res - - <br /> None( to next section) - <br /> 2.Education(Institutions,Schools) <br /> Storage <br /> Information Description Create Receive Send Store T e Format How Stored <br /> O C P E Use list <br /> Behavior Rating Scales <br /> Education Plan <br /> Questionnaires <br /> None o to next section) <br /> 3.Financial <br /> Storage <br /> Information Description Create Receive Send More Type Format Now Stored <br /> O C P E Use list <br /> 13ankinglDirect Deposit <br /> Billing/Remittance Advices <br /> CAP or Respite Determinations <br /> Claims Irtfc^nation Insurance,Billing) <br /> Conesponuence <br /> Funding Justifications with Details Grants,etc.) <br /> Questionnaires,Forms,Other(i.e.,Medicaid <br /> he( o to next section <br /> July 2001-Version 4 HIPAA 2 <br />