Self-Declaration - Sample Form
Year Developed: 2017
Resource Type: Template .Primary Audience: Administrative Staff
Secondary Audience: Enabling Services
Language(s): English
Developed by: National Center for Farmworker Health (See other resources developed by this organization).
Resource Summary: Sample form for patient self-declaration. Self-declaration is a practical mechanism to document family income and family size for individual having difficulty to show other documents.
Resource Topic: Special and Vulnerable Populations,
Resource Subtopic: Patient-Centered Health Outcomes, Patient Engagement, Population Health, Program and Services.
Keywords: Agricultural Workers , Hispanic Americans/Lations, Latinas , Access to Care.This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $6,625,000 with 0 percentage financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.