Emergency Departments Paper and Pencil Questionnaire

Form Approved

OMB No. 0920-XXXX

Expiration Date XX/XX/20XX

ATTACHMENT 16

PAPER AND PENCIL QUESTIONAIRE

Routine HIV Testing in Emergency Departments

Statement of burden for paper and pencil questionnaire

Public reporting burden of this collection of information is estimated to average 10 minutes per response including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX)

1. How many years have you been practicing emergency medicine since completing your residency?

___________

2. What is your specialty?

______________________

3. Estimate, as best as possible, the percentage of the patients you see fitting each of the following racial or ethnic groups.

____ % White

____% African American

____ % Asian

____ % Hispanic or Latino

____ % Native Hawaiian or other Pacific Islander

____ % American Indian or Alaska Native

4. Which of the following categories best describes the community from which your department primarily draws patients?

Urban

Suburban

Rural

Mix

5. Indicate, as best as possible, the percentage of the patients you see that use each of the following payment types for services.

______% Fee-for-Service or indemnity

______% Managed Care

______% Medicare

______% Medicaid

______% Military Health Care (TRICARE) or Veteran’s Administration benefits (VA)

______% State or Local Sponsored Health Plan

______% Private Pay

______% Uninsured

______% Other:______________________

6. Do you test patients for HIV in your department?

Yes

No (Skip to Question 15)

7. What type of HIV test do you use?

Venipuncture

Finger prick

Oral swab

8. How many HIV tests do order in a typical month?

________

9. What percentage of the HIV tests were performed because the patient requested to be tested?

________%

10. Currently, how many patients living with HIV do you see in a month?

________

11. How many cases of HIV have you diagnosed in the past 12 months?

________

12. Thinking about the health issues affecting your patients, how [relevant/important?] is HIV?

Very

Somewhat

Not

13. What challenges do you see in adopting routine HIV testing?

Cost

Time

Lack of information

Patient objections

Patient population not at risk

Handling HIV positive tests

State requirements for counseling

Other__________________

Attachment 17 Page 3 of 3