<p> Project Participation Opportunity: Partner Interest Form</p><p>PROJECT 3.D.II – EXPANSION OF THE HOME ENVIRONMENTAL ASTHMA MANAGEMENT PROGRAM TO REDUCE AVOIDABLE ER USE AND HOSPITALIZATIONS RELATED TO ASTHMA, BY MEANS OF IMPLEMENTING OR EXPANDING HOME-BASED SERVICES TARGET AUDIENCE: PRIMARY CARE PROVIDERS THAT TREAT PEDIATRIC AND/OR ADOLESCENT POPULATIONS This Project Participation Opportunity is intended for OneCity Health Community Partners only; NYC Health + Hospital sites should not submit an expression of interest, and will be selected for early implementation through a separate process. Please complete and submit this form to OneCity Health at [email protected] by Thursday January 27, 2016. Note that submission of this form will serve as your attestation to meeting the minimum project participation qualifications. </p><p>Partner Information</p><p>Agency Name: Click here to enter text. Address: Click here to enter text. Contact Person: Click here to enter text. Email: Click here to enter text. Phone Number: Click here to enter text.</p><p>Current Asthma Activities in your practice</p><p>Please check the boxes below detailing which activities/ services, if any, are currently available to pediatric patients at your primary care site Asthma Education (individual) Asthma Education (group) Referral to home remediation services Asthma action plan (Please specify the plan used by your primary care site) Click here to enter text. Community Health Worker program for asthma</p><p>PLEASE CONTINUE ON THE FOLLOWING PAGE.</p><p>Project Participation Opportunity: Partner Interest Form Page 1 of 4 Project Participation Opportunity: Partner Interest Form</p><p>PROJECT 3.D.II – EXPANSION OF THE HOME ENVIRONMENTAL ASTHMA MANAGEMENT PROGRAM TO REDUCE AVOIDABLE ER USE AND HOSPITALIZATIONS RELATED TO ASTHMA, BY MEANS OF IMPLEMENTING OR EXPANDING HOME-BASED SERVICES</p><p>Project Participation Opportunity: Partner Interest Form Page 2 of 4 Project Participation Opportunity: Partner Interest Form</p><p>PROJECT 3.D.II – EXPANSION OF THE HOME ENVIRONMENTAL ASTHMA MANAGEMENT PROGRAM TO REDUCE AVOIDABLE ER USE AND HOSPITALIZATIONS RELATED TO ASTHMA, BY MEANS OF IMPLEMENTING OR EXPANDING HOME-BASED SERVICES</p><p>III: Practice Details</p><p>1. How many unique pediatric and adolescent (0-17 y/o) primary care patients were served by your facility during CY 2015? Click here to enter text.</p><p>2. What percent of your pediatric and adolescent (0-17 y/o) primary care patients have an asthma diagnosis? Click here to enter text.</p><p>3. How many pediatric or adolescent (0-17 y/o) primary care visits did your facility provide during CY 2015? Click here to enter text.</p><p>IV: Staffing and capacity. Please check all the roles that currently comprise your practice and use the text boxes to enter the number</p><p>Physicians FTE: Click here to enter text. Nurse Practitioners FTE: Click here to enter text. Nurses FTE: Click here to enter text. Physician Assistants FTE: Click here to enter text. Social Workers FTE: Click here to enter text. Community Health Workers FTE: Click here to enter text. Asthma Educators FTE: Click here to enter text. </p><p>V: Technology to Support Tracking and Documentation</p><p>Which of the following are available in your practice to support documenting, tracking and reporting? (check all that apply)</p><p> iPad / tablet Laptops Desktops None of the Above Other (specify): Click here to enter text.</p><p>PLEASE CONTINUE ON THE FOLLOWING PAGE.</p><p>Project Participation Opportunity: Partner Interest Form Page 3 of 4 Project Participation Opportunity: Partner Interest Form</p><p>PROJECT 3.D.II – EXPANSION OF THE HOME ENVIRONMENTAL ASTHMA MANAGEMENT PROGRAM TO REDUCE AVOIDABLE ER USE AND HOSPITALIZATIONS RELATED TO ASTHMA, BY MEANS OF IMPLEMENTING OR EXPANDING HOME-BASED SERVICES VI: Areas Served</p><p>Bronx Brooklyn Manhattan Queens Central Bronx Central Brooklyn Central Harlem Northeast Queens Bronx Park and Southwest Chelsea and North Queens Fordham Brooklyn Clinton Central Queens High Bridge and Borough Park East Harlem Jamaica Morrisania Canarsie and Gramercy Park Northwest Queens Hunts Point and Flatlands and Murray Hill Mott Haven Southern Brooklyn Greenwich Village West Central Kingsbridge and and Soho Queens Northwest Riverdale Rockaways Brooklyn Lower Manhattan Northeast Bronx Flatbush Lower East Side Southeast Queens Southeast Bronx East New York and Upper East Side Southwest Queens New Lots Upper West Side West Queens Greenpoint Inwood and Sunset Park Washington Heights Bushwick and Williamsburg</p><p>Project Participation Opportunity: Partner Interest Form Page 4 of 4</p>