This educational intervention tool in this appendix will be provided for English speaking participants identified as visual learners. The participant will be instructed to read the documents and pay attention to the explanations for the areas labeled.
City General Hospital
Radiology Department
Upper GI Patient Instructions
Appointment Date:__
Appointment Time:__
Your doctor has ordered an x-ray of your stomach. The test will take 1 to 2
hours. When you come for the test, you must have an empty stomach. The
night before the test, only eat a little snack, such as fruit, toast, and jelly,
with coffee or tea. Do not eat breakfast. Do not even drink water. Do not eat
or drink anything at all after midnight until after you have had the x-ray. Call
the Radiology Department at 555-1234 if you have any questions.
Your doctor has ordered an x-ray of your stomach.
Radiology Department
Upper GI Patient Instructions
te:__
me:__
Your doctor might tell you that you need to have a
diagnostic test. This means that you need to have a test
to see if there is something wrong and what it is. The
test might be an x-ray, lab work, or other simple test.
You should know what kind of test you will have and if
it is on a certain part of your body. The radiology
department is where x-rays are taken and the upper GI
is the body system where the stomach is located.
City General Hospital
Radiology Department
Upper GI Patient Instructions
Appointment Date:____________
Appointment Time:____________
Your doctor has ordered an x-ray of your stomach. The test will take 1 to 2
hours. When you come for the test, you must have an empty stomach. The
night before the test, only eat a little snack, such as fruit, toast, and jelly,
with coffee or tea. Do not eat breakfast. Do not even drink water. Do not eat
or drink anything at all after midnight until after you have had the x-ray. Call
the Radiology Department at 555-1234 if you have any questions.
The test will take 1 to 2
Appointment Date:____________
Appointment Time:____________
tions
The instructions or order will
also include information
about the date and time of the
test. You might be told how
long a test might take. It
might only take a few
minutes, or it might take a
few hours.
City General Hospital
Radiology Department
Upper GI Patient Instructions
Appointment Date:___
Appointment Time:___
Your doctor has ordered an x-ray of your stomach. The test will take 1 to 2
hours. When you come for the test, you must have an empty stomach. The
night before the test, only eat a little snack, such as fruit, toast, and jelly,
with coffee or tea. Do not eat breakfast. Do not even drink water. Do not eat
or drink anything at all after midnight until after you have had the x-ray. Call
the Radiology Department at 555-1234 if you have any questions.
hours. When you come for the test, you must have an empty stom
__
___
When the doctor orders the test, you might have some
things that you need to do to get ready for it. Some tests
require you to have an empty stomach. This may be
called, "fasting." If this is the case, you will be told how
long you should go without eating. If your test is ordered
to be done in the morning, you may be told not to eat or
drink after ten o'clock at night or after midnight.
City General Hospital
Radiology Department
Upper GI Patient Instructions
Appointment Date:____________
Appointment Time:____________
Your doctor has ordered an x-ray of your stomach. The test will take 1 to 2
hours. When you come for the test, you must have an empty stomach. The
night before the test, only eat a little snack, such as fruit, toast, and jelly,
with coffee or tea. Do not eat breakfast. Do not even drink water. Do not eat
or drink anything at all after midnight until after you have had the x-ray. Call
the Radiology Department at 555-1234 if you have any questions.
mach. The
night before the test, only eat a little snack, such as fruit, toast, and jelly,
with coffee or tea. Do not eat breakfast. Do not even drink water. Do not eat
or drink anything at all after midnight until after y
_
_
You may be told that there are foods or
drinks that you should not have before
your test. If you have medicine that
you always take in the morning, you
might be told if you can take it with a
sip of water or if you should wait until
after the test.
City General Hospital
Radiology Department
Upper GI Patient Instructions
Appointment Date:____________
Appointment Time:____________
Your doctor has ordered an x-ray of your stomach. The test will take 1 to 2
hours. When you come for the test, you must have an empty stomach. The
night before the test, only eat a little snack, such as fruit, toast, and jelly,
with coffee or tea. Do not eat breakfast. Do not even drink water. Do not eat
or drink anything at all after midnight until after you have had the x-ray. Call
the Radiology Department at 555-1234 if you have any questions.
you have had the x-ray. Call
the Radiology Department at 555-1234 if
_
_
The order for the test might also
include a phone number of who to
call if you have questions about the
test. Any time you have questions
about how to get ready for a test, you
should ask.
Temporary Assistance for Needy Families (TANF) Application State of XXXX
About the Program
The program provides temporary financial assistance to help pay for food, shelter, utilities, and expenses other than medical. The TANF program is available to for
pregnant women and families with one or more dependent children under the age of 19. Changes
If there are any changes in the size of my household, amount of income, living arrangements, property, or attendance in school, I agree that I will inform the agency within 10 days of the change.
Adding a Person
If a client wishes to add a person to be in the case, a written request is required. The date should be provided in 6-digit format to provide month, day, and year of the start of the eligibility approval period. It the added person is determined to be eligible for a three month period before the request, medical eligibility may be backdated to the first day of the first month that the person became eligible
Right to Appeal
If I am not satisfied with the action taken on my application, I understand that I have the right to a fair appeal hearing. I may ask for a fair appeal hearing by contacting the office where I submitted my application or by submitting a written request for appeal to: State of XXX Bureau of Appeals, 123 Main Street, Anywhere, USA 12345, or by calling 1- 800-555-1111.
Applicant Signature
Applicant: _________________________________________ Date: ____________ By providing my signature on this form, I am indicating my understanding that I may be subject to criminal and/or civil prosecution if I have provided false information or intentionally failed to disclose information. I understand that I am providing consent for investigation to confirm and verify information I have provided related to my request for public assistance. I further understand the requirement for my cooperation in efforts for verification of my information by Federal, State, and Local officials. I certify that I have provided truthful information on this application form to the best of my knowledge and understand that failure to do so may be considered under the penalty of perjury.
The program provides temporary financial assistance to help pay for food, shelter, utilities, and expenses other than medical. The TANF program is available to for pregnant women and families with one or more dependent children under the age of 19.
The Temporary Assistance for Needy Families (TANF) program helps help pay for food, shelter, utilities, and non-medical expenses. You may be able to get money through this program if you are pregnant or have at least one child that you support.
Temporary Assistance for Needy Families (TANF) Application State of XXXX
About the Program
The program provides temporary financial assistance to help pay for food, shelter, utilities, and expenses other than medical. The TANF program is available to for
pregnant women and families with one or more dependent children under the age of 19. Changes
If there are any changes in the size of my household, amount of income, living arrangements, property, or attendance in school, I agree that I will inform the agency within 10 days of the change.
Adding a Person
If a client wishes to add a person to be in the case, a written request is required. The date should be provided in 6-digit format to provide month, day, and year of the start of the eligibility approval period. It the added person is determined to be eligible for a three month period before the request, medical eligibility may be backdated to the first day of the first month that the person became eligible
Right to Appeal
If I am not satisfied with the action taken on my application, I understand that I have the right to a fair appeal hearing. I may ask for a fair appeal hearing by contacting the office where I submitted my application or by submitting a written request for appeal to: State of XXX Bureau of Appeals, 123 Main Street, Anywhere, USA 12345, or by calling 1- 800-555-1111.
Applicant Signature
Applicant: __________________________________________ Date: ____________ By providing my signature on this form, I am indicating my understanding that I may be subject to criminal and/or civil prosecution if I have provided false information or intentionally failed to disclose information. I understand that I am providing consent for investigation to confirm and verify information I have provided related to my request for public assistance. I further understand the requirement for my cooperation in efforts for verification of my information by Federal, State, and Local officials. I certify that I have provided truthful information on this application form to the best of my knowledge and understand that failure to do so may be considered under the penalty of perjury. If there are any changes in the size of my household, amount of income, living arrangements, property, or attendance in school, I agree that I will inform the agency within 10 days of the change.
Temporary Assistance for Needy Families (TANF) Application State of XXXX
About the Program
The program provides temporary financial assistance to help pay for food, shelter, utilities, and expenses other than medical. The TANF program is available to for
pregnant women and families with one or more dependent children under the age of 19. Changes
If there are any changes in the size of my household, amount of income, living arrangements, property, or attendance in school, I agree that I will inform the agency within 10 days of the change.
Adding a Person
If a client wishes to add a person to be in the case, a written request is required. The date should be provided in 6-digit format to provide month, day, and year of the start of the eligibility approval period. It the added person is determined to be eligible for a three month period before the request, medical eligibility may be backdated to the first day of the first month that the person became eligible
Right to Appeal
If I am not satisfied with the action taken on my application, I understand that I have the right to a fair appeal hearing. I may ask for a fair appeal hearing by contacting the office where I submitted my application or by submitting a written request for appeal to: State of XXX Bureau of Appeals, 123 Main Street, Anywhere, USA 12345, or by calling 1- 800-555-1111.
Applicant Signature
Applicant: ___________________________________________ Date: ____________ By providing my signature on this form, I am indicating my understanding that I may be subject to criminal and/or civil prosecution if I have provided false information or intentionally failed to disclose information. I understand that I am providing consent for investigation to confirm and verify information I have provided related to my request for public assistance. I further understand the requirement for my cooperation in efforts for verification of my information by Federal, State, and Local officials. I certify that I have provided truthful information on this application form to the best of my knowledge and understand that failure to do so may be considered under the penalty of perjury.
If a client wishes to add a person to be in the case, a written request is required. The date should be provided in 6-digit format to provide month, day, and year of the start of the eligibility approval period. It the added person is determined to be eligible for a three month period before the request, medical eligibility may be backdated to the first day of the first month that the person became eligible
If you want TANF for a family member, you must apply in writing. The effective date will be adjusted to the first day of the month that the addition is found to be eligible.
Temporary Assistance for Needy Families (TANF) Application State of XXXX
About the Program
The program provides temporary financial assistance to help pay for food, shelter, utilities, and expenses other than medical. The TANF program is available to for
pregnant women and families with one or more dependent children under the age of 19. Changes
If there are any changes in the size of my household, amount of income, living arrangements, property, or attendance in school, I agree that I will inform the agency within 10 days of the change.
Adding a Person
If a client wishes to add a person to be in the case, a written request is required. The date should be provided in 6-digit format to provide month, day, and year of the start of the eligibility approval period. It the added person is determined to be eligible for a three month period before the request, medical eligibility may be backdated to the first day of the first month that the person became eligible
Right to Appeal
If I am not satisfied with the action taken on my application, I understand that I have the right to a fair appeal hearing. I may ask for a fair appeal hearing by contacting the office where I submitted my application or by submitting a written request for appeal to: State of XXX Bureau of Appeals, 123 Main Street, Anywhere, USA 12345, or by calling 1- 800-555-1111.
Applicant Signature
Applicant: ________________________________________ Date: ____________ By providing my signature on this form, I am indicating my understanding that I may be subject to criminal and/or civil prosecution if I have provided false information or intentionally failed to disclose information. I understand that I am providing consent for investigation to confirm and verify information I have provided related to my request for public assistance. I further understand the requirement for my cooperation in efforts for verification of my information by Federal, State, and Local officials. I certify that I have provided truthful information on this application form to the best of my knowledge and understand that failure to do so may be considered under the penalty of perjury.
If I am not satisfied with the action taken on my application, I understand that I have the right to a fair appeal hearing. I may ask for a fair appeal hearing by contacting the office where I submitted my application or by submitting a written request for appeal to: State of XXX Bureau of Appeals, 123 Main Street, Anywhere, USA 12345, or by calling 1- 800-555-1111.
If you do not like the decision about your eligibility, you have a right to a fair hearing. You can ask for a hearing by writing or calling the Medicaid office in the same county.
Temporary Assistance for Needy Families (TANF) Application State of XXXX
About the Program
The program provides temporary financial assistance to help pay for food, shelter, utilities, and expenses other than medical. The TANF program is available to for
pregnant women and families with one or more dependent children under the age of 19. Changes
If there are any changes in the size of my household, amount of income, living arrangements, property, or attendance in school, I agree that I will inform the agency within 10 days of the change.
Adding a Person
If a client wishes to add a person to be in the case, a written request is required. The date should be provided in 6-digit format to provide month, day, and year of the start of the eligibility approval period. It the added person is determined to be eligible for a three month period before the request, medical eligibility may be backdated to the first day of the first month that the person became eligible
Right to Appeal
If I am not satisfied with the action taken on my application, I understand that I have the right to a fair appeal hearing. I may ask for a fair appeal hearing by contacting the office where I submitted my application or by submitting a written request for appeal to: State of XXX Bureau of Appeals, 123 Main Street, Anywhere, USA 12345, or by calling 1- 800-555-1111.
Applicant Signature
Applicant: ___________________________________________ Date: ____________ By providing my signature on this form, I am indicating my understanding that I may be subject to criminal and/or civil prosecution if I have provided false information or intentionally failed to disclose information. I understand that I am providing consent for investigation to confirm and verify information I have provided related to my request for public assistance. I further understand the requirement for my cooperation in efforts for verification of my information by Federal, State, and Local officials. I certify that I have provided truthful information on this application form to the best of my knowledge and understand that failure to do so may be considered under the penalty of perjury.
Applicant: ___________________________________________ Date: ______________
By providing my signature on this form, I am indicating my understanding that I may be subject to criminal and/or civil prosecution if I have provided false information or intentionally failed to disclose information. I understand that I am providing consent for investigation to confirm and verify information I have provided related to my request for public assistance. I further understand the requirement for my cooperation in efforts for verification of my information by Federal, State, and Local officials. I certify that I have provided truthful information on this application form to the best of my knowledge and understand that failure to do so may be considered under the penalty of perjury.
When you apply for Medicaid, you must agree to give true facts to see if you can get it. You must state that you understand that the county Medicaid office must be able to prove all facts you give them.
Appendix J: Visual Learning Style Intervention – Spanish
The educational intervention tool in this appendix will be provided for Spanish speaking participants identified as visual learners. The participant will be instructed to read the documents and pay attention to the explanations for the areas labeled.