18a 18a_MCH Jurisdictional Survey Eligibility and Cons

Pali en MCH doaropwe en kihda mweimwei oh ong koasouh ong ihs me wahrong.

Ihs me warong

Kaselelehlie, edei _____. Ih iang toweda pwin en koasouh, pwen wewekila laud roson mwau en nonoh kan oh seri kan nan wehi en [American Samoa/Federated States of Micronesia/Marshall Islands/Northern Mariana Islands/Palau]. Ma komw iang sapeng kalelepak kan nan douloal wet, komw pahn anahne sapeng kalelepak kan pid duwen ahmw roson oh roson en nomw seri kan.

[If respondent is Female go to 1, if respondent is Male or you are unsure, go to question 4]

1. Se diarada komwi ni soh lihpilipil pwehn iang douloal wet. Mie kalelepak kei pwehn kasahledah me komwi kak iang warong douloal wet?

Ei [Go to 2]
Soh [Thank individual for their time and leave]

Sohte men Sapeng [Thank individual for their time and leave]

2. Komw sounpar 18 de laud sang?

Ei [Go to 3]
Soh [Go to 4]

Kahng Sapeng [Thank individual for their time and leave]

3. Mie seri sounpar 0 lel 17 me kin mihmi nan ihmwet oh komwi ah nohno de sounsilasil?

Ei [Go to informed consent]
Soh [Go to 4]

Sohte men Sapeng [Thank individual for their time and leave]

4. Mie lih nan mimih sounpar 18 de laud sang me nainiki seri sounpar 0 lel 17 me kin mihmi ni imwomwi me I kak koasoaiong?

Ei [Go to beginning]

Ei, ahpw eh sohte kak [Go to 5]
Soh [Thank individual for their time and leave]

Kahng Sapeng [Thank individual for their time and leave]

5. Mie ansou mwahu me I kak pwurodo wasa kiset oh koasoaiong liho?

Ei [Write down time]

Soh [Thank individual for their time and leave]

Kahng Sapeng [Thank individual for their time and leave]

Iren Pwungki Kan

[INFORMED CONSENT OBTAINED AFTER DETERMINING ELIGIBLE CHILD(REN) IN THE HOUSEHOLD]

Pwouselate koaskoasoane douloal ieu nan [American Samoa/Federated States of Micronesia/Marshall Islands/Northern Mariana Islands/Palau] pwehn esehla laud duwen en nohno oh seri kan arail rosohn. Douloal wet iang pirokram Title V MCH Block Grant, me ale mwoni sang Health Resources and Services Administration (HRSA).

Ahmw pasapeng kan pahn sewese pirokram en nohno oh seri kan esehla laud duwen en nohno or seri kan arail kehl nan sapwomwi, oh re pahn doadoangiki sapeng pwukat pwehn kakehlailih papah kan ohng peneinei kan. Douloal wet pahn anahne minit 50 oh kalelepak kan pahn pekipek duwen ahmw kehl oh en nomwi seri kan arail kehl.

Komw sohte anahne iang douloal wet ma komw sohte mwahuki. Insehnomw ma komw pilada en iang douloal wet. Komw sohte anahne sapeng kalelepak kan me komw sohte mwahuki.

Ekei kalelepak kan mwein pahn kahrehda komwi en kehn soansuwet karedah komwi sohte anane sahpweng.

Ma komw pilada en iang sapeng douloal wet, komw pahn ale kisakis tikitik uwen aht kapingki ahmw ansou, ahpw se sohte kak seweseikomwi ni komw sapeng kalelepak pwukat.

Ahmw pasapeng kan pahn mihmi ni rir. Ihte aramas me pahn kilang ahmw pasapeng kan iei tohndoadoahk kan en douloal wet or irail me iang tehk me se koasoane douloal wet ni mwahu. Edemwi sohte pahn mih nan douloal wet. Se pahn doadoangki nembe ieu en esehla nain ihs douloal wet, ah kaidehn edemwi.

Douloal wet sohte pahn pekipek duwen wiakawe seri.  Ahpw ma se esehla duwen wiakawe seri nan peneinei ieu, kosonned en wehi kan iding kiht en leleki polis.

Menlau tuhkiweng X ni (XXX) XXX-XXXX de XXXX ahmw kalelepak de mehn nsenoh kan pid douloal wet.  Ma mie ahmw kalelepak de mehn nsenoh kan pid amwhi pwung kan ni ahmw iang sapeng douloal wet, menlau koahlih kaun en NORC Institutional Review Board ni nembe sohte pweipwei (866) 309-0542. 

I pahn kihong komwi doaropwe wet pwe komw kak tamataman dahme I ndaiong komwi. [Provide the paper copy of the informed consent language]

1. Mie ahmw kalelepak kan?

Ei [Answer questions, then go to B]
Soh [Go to B]

Kahng Sapeng [Thank individual for their time and leave]

2. Komw mwahuki en wenewei oh sapeng kalelepak kan nan douloal wet?

Ei [Thank individual and begin the questionnaire]
Soh [Thank individual for their time and leave]

Kahng Sapeng [Thank individual for their time and leave]