Utilities Questions

AAFP Social Needs Screening Tool

 In the past 12 months has the electric, gas, oil, or water company threatened to shut off services in your home?
Yes
No
Already shut off

Accountable Health Communities Health-Related Social Needs Screening Tool

In the past 12 months has the electric, gas, oil, or water company threatened to shut off services in your home?
Yes
No
Already shut off

ACORN Screening Tool 

How often do you have trouble paying for your utilities (e.g., electric, gas, oil, water, or phone)?
Often
Sometimes
Never
Not applicable/I don’t pay for utilities

Has the electric, gas, oil, water or
phone company threatened to shut off
services in your home?
Yes
 No
Already shut off
Not applicable/I don’t pay for utilities

Arlington Screening Tool

In the last 12 months, has the electric, gas, oil or water company threatened to shut off your services in your home?
Yes/ No

Boston Medical Center-Thrive Screening Tool

Do you have trouble paying your heating or electricity bill?
Yes/ No

Health Leads Social Needs Screening Toolkit

In the last 12 months, has the electric, gas, oil, or water company threatened to shut off your services in your home?
​Yes/No

North Carolina Medicaid Screening Tool

Within the past 12 months, have you been unable to get utilities (heat, electricity) when it was really needed?
Yes/ No

PRAPARE

In the past year, have you or any family members you live with been unable to get any of the following when it was really needed
Utilities: Yes/No
Phone: Yes/No

WellRx Toolkit

Do you have trouble paying for your utilities (gas, electricity, phone)?
Yes/No

Kaiser Permanente's Your Current Life Situation Survey

In the past 3 months, did you have trouble paying for any of the following? (Select ALL that apply)
Heat and electricity

Back to the Table