RHS-15 Utilization Request and Agreement

· RHS-15 Utilization Request and Agreement

Pathways will retain your contact information in order to update you about any changes to, or new versions of, the RHS-15. We will not sell or use your information in any other way.
Date of Request: / Name:
Institution:
Department (if applicable):
Your Position:
Address 1:
City: / State: / Zip:
Country: / Email:

Statement of Agreement

¨ I understand that the purpose of this agreement is to improve the use and dissemination of the Refugee Health Screening – 15 (RHS-15). I agree to utilize RHS-15 in its current form and for its intended use unless otherwise specified in subsequent agreements. This includes:

· Using it for ages 14 and above only

· Using it in the translated targeted languages

· Using it in combination with an introductory and referral script, which may be individually adapted

¨ I will not use the RHS-15 for any for-profit purposes.

¨ I will not adapt the RHS-15 without permission.

¨ If requested, I will share data or information I have learned from using the RHS-15 for the intent to approve the screening tool.

Requestors’ signature: ______Date: ______

Requestor’s printed name: ______

Please return the form to: Pathways to Wellness

C/O Beth Farmer

Lutheran Community Services NW
4040 S 188th Street, Suite #200, SeaTac, WA 98188

You may fax to: 206-838-2680

You may scan to:

Pathways to Wellness is a project of Lutheran Community Services Northwest, Asian Counseling and Referral Services, Public Health Seattle & King County, and Michael Hollifield, M.D. Generously funded by the Robert Wood Johnson Foundation, The Bill and Melinda Gates Foundation, United Way of King County, The Medina Foundation, Seattle Foundation, and the Boeing Employees Community Fund.

ã Pathways to Wellness: Integrating Refugee Health and Well-being