Prevention Is Care (PIC) Paper and Pencil Questionnaire

Form Approved

OMB No. 0920-XXXX

Expiration Date XX/XX/20XX

ATTACHMENT 17

PAPER AND PENCIL QUESTIONAIRE

Prevention is Care (PIC)

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 medicine?

______

We recognize that many physicians split their time between private practices (individual or group) and practices that are public or university based. For the following set of questions, we would like you to provide responses for both these practice types as applicable to your own practice of medicine.

Private Practice

Public or University

Based Practice

2. Number of patients you see in a month.

______

______

2. Total number of patients in your practice.

______

______

4. Number of HIV positive patients you see in a month.

______

______

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

White	___%
Black or African- American	___%
Asian	___%
Hispanic or Latino	___%
Native Hawaiian or Other Pacific Islander	___%
American Indian or Alaska Native	___%

White	___%
Black or African- American	___%
Asian	___%
Hispanic or Latino	___%
Native Hawaiian or Other Pacific Islander	___%
American Indian or Alaska Native	___%

6. Which of the following categories best describes the community from which your practice(s) primarily draw(s) patients

Urban	___%
Suburban	___%
Rural	___%
Mix	___%

Urban	___%
Suburban	___%
Rural	___%
Mix	___%

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

Employer/ Third Party Insurance	___%
Medicare	___%
Medicaid	___%
Military Health Care	___%
State or Local Sponsored Health Plan	___%
Private Pay	___%

Employer/ Third Party Insurance	___%
Medicare	___%
Medicaid	___%
Military Health Care	___%
State or Local Sponsored Health Plan	___%
Private Pay	___%

8. Among your HIV positive patients, please estimate the percentage infected through the following modes of transmission?

Heterosexual Sex	___%
Homosexual Sex	___%
Intravenous Drug Use (IDU)	___%
Other	___%

Heterosexual Sex	___%
Homosexual Sex	___%
Intravenous Drug Use (IDU)	___%
Other	___%

9. Among your HIV positive patients, what percentages are male and female?

Males	___%
Females	___%

Males	___%
Females	___%

10. Do any of the practices or clinics in which you see patients receive Ryan White Care Act Funding?

Yes No

11. Do you screen your HIV positive patients for behavioral risk factors?

Yes

No

11. How often do you screen your HIV positive patients for behavioral risk factors?

At the first visit only

Annually

Several times during the year

At every visit

11. What are some of the challenges in incorporating behavioral risk factor screening in your practice?

Time

Cultural issues

Patient reaction

Lack of knowledge

Lack of resources

Other

11. How helpful do you think it would be to have a tool to help you discuss behavioral risk factors with your HIV positive patients?

Not helpful

Somewhat helpful

Very helpful

Attachment 17 Page 3 of 3