THW Utilization Reporting Form

The THW reporting template is a contract requirement from the Oregon Health Authority that asks CCOs to provide THW utilization data. EOCCO will ask for this data quarterly to collect current utilization information from you and your organization.


We recognize that some of these questions may be sensitive in nature. Reporting your name and/or contact information to EOCCO is optional. Data given to EOCCO will be reported to the OHA in aggregate; you will not be identified by your answers.


If you have any questions, please contact Hannah Briggs, THW Liaison at hannah.briggs@modahealth.com or (503) 952-4995. Thank you!

Please check this box if you would like to be included in emailed updated from EOCCO regarding the Traditional Health Worker program.

Reporting Quarter*

Employment Questions

THW Type*

Which OHA THW certification do you hold?

Select or enter value
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Employer Status*

What type of organization are you employed by?

FTE Status*

Are you employed full time or less than full time as a THW?

THW Location*

What is the primary setting where you work?

Patient Satisfaction*

Did your organization conduct a patient satisfaction survey regarding THW services in the last quarter?

Briefly, what were the results of your patient satisfaction survey?

Demographic Questions

Preferred Language*

Please indicate your preferred langage.

Interpreter Status*

Are you an OHA certified or qualified interpreter?

Disability Status*

Do you identify as someone living with a disability?

Utilization Questions

EOCCO Billing and Claims*

Did you or a member of your billing team submit claims to EOCCO for the THW services you provided in the last quarter?

How many EOCCO member requests for THW services did you receive this quarter? This is the number of requests for services initiated by members and may include multiple requests from members. If unknown, please enter "unknown."

How many times was an EOCCO member referred to you for THW services by a member of their care team? This is a total number of referrals by the care team and many include multiple referrals for members. If unknown, please enter "unknown."

How many EOCCO member services that you provided occurred in a clinical setting? If unknown, please enter "unknown."

How many EOCCO member services that you provided occurred in a community-based setting? If unknown, please enter "unknown."

Do you receive funding from any of the following sources?

If you have anything else you would like to share with EOCCO about the THW services you provided in the last quarter, please let us know here.

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