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Get VA Newcomer Health Program Supplemental Data Collection Form 2014-2024

__________ Pt #:________________________ VOLAG: _____________________________ Encounter #:_________________________________ Health District: _____________________________ Did the patient receive an initial health screening? Yes No DATE OF INITIAL ASSESSMENT:_____/______/________ If the patient did not receive a screening, why not? Moved Refused Never located Missed multiple appts.  Unknown Other_____________________________ Please provide an appropriate response.

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