Case Assistance System Evaluation - Needs Assessment CASE SDOH

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The chapter is funded by organizations that monitor social determinants of health. Social determinants of health are conditions that affect a range of health outcomes. Lupus patients may have barriers to care depending on their social determinants and/or other factors.

Completing this assessment:
1. Helps our navigators determine if there are any barriers to care that could prevent a lupus patient from
obtaining optimal health.
2. Helps funding organizations study general trends in barriers to care that lupus patients may have.
3. Allows opportunities for funding our patient navigator program in the future.

By completing the assessment, you agree to opt in to receiving guidance from the Lupus Foundation of America, Greater Ohio Chapter and you agree that some of your answers may be used to study general trends in barriers to care. Your personal information (name and contact details) will be used by the Lupus Foundation of America, Greater Ohio Chapter for office use only and will not be shared with anyone else.

Please enter your name, email and contact information.

First Name *

Last Name *

Email *

Phone Number *

Street Address 1 *

Street Address 2

City *

State *

Zip Code *

Gender *

Male

Female

Transgender Man

Transgender Woman

Gender-queer/Gender-noncomforming

Nonbinary

Prefer not to answer

Other:

Birth Date *

YYYY

Primary Race or Racial Background *

White

Black or African American

American Indian or Alaska Native

Asian

Hispanic or Latino

Pacific Islander

Prefer not to answer

Other:

Primary Language *

English

Spanish

French

Mandarin

Russian

Other:

How many people are living in your household? *

4 or more

Prefer not to answer

What is your connection to Lupus? *

I am a lupus patient.

I am a caregiver for someone with lupus.

I am a healthcare professional.

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