Partner Services Paper and Pencil Questionnaire

Formative Research to Develop Social Marketing Campaigns-Routing HIV Testing For Emergency Medicine Physicians, Prevention Is Care, and Partner Services

A18_Partner Services_Paper and Pencil Survey

Partner Services Paper and Pencil Questionnaire

OMB: 0920-0775

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Form Approved

OMB No. 0920-XXXX

Expiration Date XX/XX/20XX


ATTACHMENT 18


PAPER AND PENCIL QUESTIONAIRE


HIV Partner Services


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


  1. Number of patients you see in a month.


______

______





  1. 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



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

Yes

No


  1. 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


  1. 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


  1. 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 18 Page 3 of 3

File Typeapplication/msword
File TitleRoutine Testing
AuthorPeyton Williams
Last Modified Bytfs4
File Modified2007-10-30
File Created2007-10-30

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