Form No number No number Attachment C - Screening Script to Identify Supervisor

Attachment C

Screening Script to Identify Supervisor for Interview:

Local EMS Provider Survey – Computer Assisted Telephone Interview

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/XXXX

Screening Script to Identify Supervisor for Interview:

Local EMS Provider Survey—Computer Assisted Telephone Interview

1. Hello, my name is <INTERVIEWER NAME>. I am calling from the Battelle Seattle Research Center. I am calling on behalf of the Centers for Disease Control and Prevention. CDC is conducting a survey of EMS providers to gather data on heart disease and stroke emergency treatment protocols in use. Have I reached <CONFIRM FACILITY NAME AND ADDRESS>?

IF YES, CONTINUE WITH QUESTION 2

IF NO, RECORD FACILITY NAME AND ADDRESS BELOW

Facility name ___________________________

Address ____________________________

City, ST and Zip ____________________________

Thank you.

IF THIS IS A FIRE DEPARTMENT or EMS SERVICE THEN SKIP TO QUESTION 3

IF THIS IS A STAND ALONE AMBULANCE SERVICE THEN CONTINUE WITH QUESTION 2

Public reporting of this collection of information is estimated to average 2 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)

2. We understand that some Ambulance Services may respond to emergency calls, while others may only provide inter-facility transfer services, and in some cases they may provide both. For this study, we are only interested in talking with EMS providers that mainly respond to emergency calls, which could include using the ambulance as quick response vehicle for emergency calls. Please tell me, does your service involve the use of ground ambulances with EMTs or paramedics in response to emergency calls?

 YES  CONTINUE WITH QUESTION 3

• NO (a) WE MAINLY DO INTER-FACILITY TRANSPORT;

or

• NO (b) WE ONLY DO AIR TRANSPORT, NO GROUND AMBULANCES

 CONCLUDE THE INTERVIEW BY SAYING

I’m sorry, but our study is focusing on ground ambulance and EMS organizations that respond to emergency calls. Thank you very much for your time. Good bye. HANG UP.

3. We would like to conduct a survey with your EMS director or supervisor, or whoever is responsible for the activities of the EMS personnel in your organization. Please tell me the name, title and phone number of this person:

PROBE: IF THE PERSON IS NOT CLEAR WHO WE ARE ASKING FOR YOU MAY EXPLAIN TO THEM THAT THIS PERSON WOULD BE THE ONE RESPONSIBLE FOR THE DAY TO DAY MANAGEMENT AND SUPERVISION OF THE EMTS AND PARAMEDICS IN THE ORGANIZATION.

RECORD NAME AND PHONE NUMBER BELOW

EMS supervisor’s

First and Last Name ___________________________

Title ___________________________

Phone number ___________________________

4. May I please speak with this person now?

IF THE EMS SUPERVISOR IS AVAILABLE THEN SKIP TO QUESTION 6

IF THE EMS SUPERVISOR IS NOT AVAILABLE THEN CONTINUE

5. When is the best time to reach <EMS SUPERVISOR NAME>?

RECORD BEST TIME TO REACH EMS SUPERVISOR

Best time to reach EMS supervisor ___________________________

Thank you for your assistance. Good bye.

HANG UP AND END CALL

*************************

[When contact is made with the supervisor]

QUESTIONS FOR THE EMS SUPERVISOR

6. Hello, my name is <INTERVIEWER NAME> and I am calling from the Battelle Seattle Research Center. I am calling on behalf of the Centers for Disease Control and Prevention. CDC is conducting a survey of EMS providers to gather data on heart disease and stroke emergency treatment protocols in use. The purpose of the survey is to obtain information about the differences and similarities of EMS organizations across nine states. We are especially interested in how different providers manage patients with symptoms related to heart problems and stroke. The survey should take about 15 minutes to complete. Do you have 15 minutes now to complete the survey?

 YES  GO TO SURVEY SCRIPT – verbal consent QUESTION 4

• NO  CONTINUE WITH QUESTION 7

7. When would be the best time for you?

RECORD BEST TIME TO REACH RESPONDENT, BE AS SPECIFIC AS POSSIBLE.

Best time to call back to complete the interview ________________________

CONCLUDE THE CONTACT BY SAYING:

Thank you very much for your time, I will call you back on <CONFIRM BEST TIME> to tell you more about this study and complete the interview. Good-bye.