Fillable Bhs Template Screening Tool Submission Form (Commonwealth of Massachusetts)

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Bhs Template Screening Tool Submission Form (Commonwealth of Massachusetts)

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U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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Last revised 3.9.2016
CBHI Screening Tool Review Submission Form
Please type in your responses and send your completed form to EHS.CBHIscreeningtools@state.ma.us
Your Name:
Email address:
Phone number:
Name of the screening tool:
Please give the web address where the tool can be viewed ( or attach a copy):
What condition(s) does the tool screen for?
Who completes the tool (i.e., is it administered by the provider or by a family member)?:
For what range of ages is the tool intended (infants, toddlers, adolescents, etc)?
In what languages (other than English) is the tool available?:
What is the cost, if any, for this tool?:
Please briefly summarize the evidence that supports the tool’s reliability and validity for the conditions it
screens for, or provide links to supporting articles that contain this information.
Please explain why this screening tool should be added to the current menu of approved screening tools.
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Bhs Template Screening Tool Submission Form (Commonwealth of Massachusetts)

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Completed 26 July 2020

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