WSI_ Refugee Health Screener 15 (RHS-15) Utilization Agreement

Refugee Health Screener 15 (RHS-15) Utilization Agreement
Thank you for your interest in the RHS-15. The RHS-15 was developed by © Pathways to Wellness:Integrating Refugee Health and Well-being, 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, M.J. Murdock Charitable Trust, Seattle Foundation, and the Boeing Employees Community Fund.
Name *

First Name Last Name
Organization *
Agency, Program, Etc.
Organization Type *
Role within Organization *
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Responsible Use Agreement *

I agree to utilize RHS-15 in its current form and for its intended use unless otherwise specified in subsequent agreements. I will utilize the RHS-15 for ages 14 and above only. I will utilize the RHS-15 in the translated targeted languages. I will utilize the RHS-15 in combination with an introductory and referral script, which may be individually adapted to our setting and locale. I will not use the RHS-15 for any for-profit purposes. I will not adapt the RHS-15 without permission.
After clicking submit, you will be redirected to a DropBox account where you will find the RHS-15 materials. If you have any problems accessing the materials, please contact War Survivors Institute at:

info@warsurvivors.org

Thank you from the Pathways to Wellness team at War Survivors Institute for your commitment to supporting the health and well-being of refugees and migrants.
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