Digital Navigator Intake

"*" indicates required fields

Digital Navigators on behalf of Clients in WA State

This form is used by Digital Navigators to capture information about individual interactions with clients of theirs in Washington State.

Digital Navigator

Enter Navigator Name

Organization Name*

Client Name

County*

Zip Code*

ZIP Code

Interaction Type*

Helping categorize interactions allows for better understanding of the depth and breadth of the support given or needed to the client.

Client Age*

Gender Identity*

Client Race*

Demographic Data

Questions below enable analysis of how these demographic factors may be impacting digital access and/or understanding of how to use it.

Is the client living in a Rural area?*

Yes

No - Urban Setting

Prefer not to disclose

Is the client living with disabilities?

Yes

No

Prefer not to disclose

Does the client speak English as a second language and/or have a low English proficiency?*

Yes

No

Prefer not to disclose

Is the client deaf or hard of hearing?*

Yes

No

Prefer not to disclose

Is the client currently incarcerated, or has been incarcerated in the past?*

Yes to either

No to either

Prefer not to disclose

Is the client a veteran?*

Yes

No

Prefer not to disclose

Is the client an immigrant, refugee, or an asylum seeker?*

Yes

No

Prefer not to disclose

Is the client receiving Medicare or Medicaid?*

Yes

No

Prefer not to disclose

Does the client qualify for SNAP or Federal Public Housing Assistance?*

If so, they might also qualify for offers related to digital services.

Yes

No

Prefer not to disclose

Is the client at 150% or below of the US Federal Poverty Line?*

Yes

No

Prefer not to disclose

Additional Comments (Optional)

Please use this section to capture follow up needs, specific challenges, or other relevant information to help tell the client story.

Email

This field is for validation purposes and should be left unchanged.