Survey for Physicians in Reference Group

Form Approved _______

OMB No_____________

Exp. Date xx/xx/20xx___

PMR/F Program Evaluation

Survey Questions for Physicians in Reference Group: DRAFT

(EIS Graduates)

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PMR/F Program Evaluation

Survey Questions for Physicians in Reference Group: DRAFT

(EIS Graduates)

(Note: This will be electronic so the spaces for answers will be longer)

1. Demographics

P-Reference-A1. What is your primary work affiliation? (check only one)

Government:		Medical Care Setting:
	CDC		Private Practice
	Other HHS Agency		HMO
	Other Federal Agency		Private Hospital/Clinic
	State Health Dept./Govt.
	Local Health Dept./Govt.
	International Health Agency/Govt.
Academic:		Others:
	Medical School		Foundation/Association
	School of Public Health		Industry
	Other Academic Institution		Private Business (other than patient care)
	Residency, Fellowship, Grad Study		Other
	What specialty____________________		Please specify______________

P-Reference-A2. What is your primary job title (e.g., staff epidemiologist, activity chief, division director, staff physician, medical director, associate professor, agency director, chief executive officer).___________________________

P-Reference-A3. How long have you worked in this position? _____ year(s) ______ month(s)

P-Reference-A4. What is your primary responsibility within your organization?

a. Technical/Scientific staff

b. Clinician

b. Manager/ Leader

c. Senior Manager/Senior Leader

f. Other (Please specify)

P-Reference-A5. Was this your first position since graduating from EIS?

1. Yes

2. No

If Yes, skip to A15

If No, go to A6

P-Reference-A6. What was your previous position and work affiliation? _______________________

P-Reference-A7. How long had you worked in this position? _____ year(s) ______ month(s)

P-Reference-A8. What was your primary responsibility within your organization?

a. Technical/Scientific staff

b. Clinician

b. Manager/ Leader

c. Senior Manager/Senior Leader

f. Other (Please specify)

P-Reference-A9. Was this your first position since graduating from EIS?

1. Yes

2. No

If Yes, skip to A15

If No, go to A10

P-Reference-A10. What was your previous position and work affiliation? __________________________

P-Reference-A11. How long had you worked in this position? _____ year(s) ______ month(s)

P-Reference-A12. What was your primary responsibility within your organization?

a. Technical/Scientific staff

b. Clinician

b. Manager/ Leader

c. Senior Manager/Senior Leader

f. Other (Please specify)

P-Reference-A13. Was this your first position since graduating from EIS?

3. Yes

4. No

If Yes, skip to A15

If No, go to A14

P-Reference -A14. What was your first position after graduating from EIS?___________________

P-Reference-A15. Please select the statement that best describes the function of your current position.

1. I spend more than 50% of my work time on work that contributes to the health of a population

2. I spend more than 50% of my work time taking care of patients

3. I spend more than 50% of my work time in some other role

P-Reference-A16. Do you administer or manage a public health, community health, or preventive medicine program, department, or agency?

1. Yes

2. No

If Yes, go to A17

If No, skip to B1

P-Reference-A17. How many staff are in the department/group that you manage?___________

P-Reference-A18. How large is the budget that you administer or manage?______________

P-Reference-A19. What is the size of the population served by your program?________________

B. Education

P-Reference-B1. What year did you graduate from medical school? ___________

P-Reference-B2. Did you complete a residency before graduating from EIS? ________________

a. Yes

b. No

If Yes, go to B3

If No, Skip to B4

P-Reference-B3. What was your area of specialty during the residency you completed? _______

P-Reference-B4. Did you obtain your MPH or equivalent degree prior to entering EIS?

1. Yes

2. No

P-Reference-B5. This question is N/A for this group.

P-ReferenceB6. This question is N/A for this group.

P-Reference-B7. This question is N/A for this group.

P-Reference-B8. This question is N/A for this group.

P-Reference –B9. This question is N/A for this group.

P-Reference-B10. This question is N/A for this group.

P-Reference-B11. What years were you in EIS?

1. 1990-1992

2. 1991-1993

3. 1992-1994

4. 1993-1995

5. 1994-1996

6. 1995-1997

7. 1996-1998

8. 1997-1999

9. 1998-2000

10. 1999-2001

11. 2000-2002

12. 2001-2003

13. 2002-2004

14. 2003-2005

15. 2004-2006

P-Reference-B12. What was your assignment site during EIS?

a. CDC or other Federal Agency

b. State, County, or Local Health Department

P-Reference-B13. This question is N/A for this group.

P-Reference-B14. This question is N/A for this group.

P-Reference-B15. This question is N/A for this group.

P-Reference-C1. This question is N/A for this group.

P-Reference-C2. Please indicate whether and in what capacity you perform these leadership skills and how well your CDC training prepared you to perform these skills?

Leadership Skills and Functions	C2.1. * Did EIS provide you with the foundation to develop this skill? SA-A-N-D-SD	C2.2. This question is N/A for this group.	C2.3. Do you perform this function in your current position? Yes/No If yes, go toC.2.4 --> If no, go to C.3 (below)	C2.4. If Yes, What is your most senior role in this capacity: Participant Lead Executive Oversight
a. Identifying public health priorities and setting goals and objectives for an organizational unit
b. Identifying capacity and responsibilities and implementing strategies to achieve public health goals and priorities for an organizational unit
c. Building strategic alliances with internal and external partners to address public health priorities
d. Building and maintaining the organization’s capacity to achieve goals and objectives
e. Providing leadership and direction for the development  and evaluation of policies, procedures, and performance standards within an organization and among collaborating agencies
f. Planning, implementing and evaluating PH/PM programs
g. Setting mission and direction for your organizational unit

KEY: Strongly Agree (SA), Agree (A), Neutral (N), Disagree (D), and Strongly Disagree (SD),

(N/A) - Did not take this component of the practicum

P-Reference-C3. This question is N/A for this group.

D. Relevancy and Preparation

P-Reference-D1. This question is N/A for this group.

P-Reference-D2. This question is N/A for this group.

P-Reference-D3. This question is N/A for this group.

P-Reference-D4. This question is N/A for this group.

P-Reference-D5. This question is N/A for this group.

P-Reference-D6. This question is N/A for this group.

E. Contributions to PH/PM

P-Reference-E1. Since you graduated from EIS, how many of the following have you written and published in the field of public health and/or preventive medicine?

1. Books ____

2. Book-chapters ____

3. Papers in peer-reviewed journals ____

4. Abstracts in peer-reviewed journals ____

5. Publications for lay audiences ____

P-Reference-E2. Have you held an office in a professional association since graduating from EIS?

a. Yes

b. No

If Yes, go to E3

If no, skip to E4

P-Reference-D3. In which professional associations have you held office since graduating from EIS?

E3.1 Professional Association	E3.2 Office(s) held	E3.3 Year(s)
a.
b.
c.

P-Reference-E4. What would you describe as your most important contribution(s) or accomplishment(s) to the field of public health and/or preventive medicine? _________________________________

P-Reference-E5. Have you served as a subject matter expert on public health/ preventive medicine issues? (Example: before legislative bodies, senior leadership in organizations, and lay groups/audiences)

a. Yes

b. No

If Yes, go to E6

If no, skip to F1

P-Reference-E6. Please Specify: _____________________

F. Added Value

P-Reference-F1. This question is N/A for this group.

P-Reference-F2. This question is N/A for this group

P-Reference-F3. This question is N/A for this group?

P-Reference-F4. This question is N/A for this group

P-Reference-F5. This question is N/A for this group

G. Optional Questions

P-Reference-G1. What is your sex?

a. Male

b. Female

P-Reference-G2. What is your ethnicity?

a. Hispanic or Latino

b. Not Hispanic or Latino

P-Reference-G3. What is your race? (Select one or more)

a. American Indian or Alaska Native

b. Asian

c. Black or African-American

d. Native Hawaiian or other Pacific Islanders

e. White

EXTRA Questions for physicians in Reference Group only. Will not be asked of anyone else

P-Reference-X1. Did you attend a PMR after leaving EIS?

a. Yes

b. No

If yes, go to X2

If no, END

P-Reference-X2. Which PMR did you attend? _________________________________

P-Reference-X3. What were your reasons for selecting that PMR? Please list:____________________

P- Reference-X4. What year did you graduate from the PMR?

P- Reference-X5. Did you take the American Board of Preventive Medicine (ABPM) Board exam?

a. Yes

b. No

If Yes, go to X6

If no, END

P-Reference- X6. What influenced your decision to take the Board Exam? ______

P-Reference –X7. When did you sit for the board exam that you passed?

1. 1997

2. 1998

3. 1999

4. 2000

5. 2001

6. 2002

7. 2003

8. 2004

9. 2005

10. 2006

11. 2007

12. 2008

END