Health Care Practitioners' Responses to Medical Device Labeling

APPENDIX E

Questionnaire for Participants

DRAFT 10.25.10

1. What is the type of setting of your primary practice location?

   1. Urban

   2. Rural

   3. Suburban

   4. Other (please specify)

2. What is the approximate racial/ethnic makeup of your patient population:

   1. African American/Black ___%

   2. Hispanic/Latino ___%

   3. Caucasian/White___%

   4. Asian or Pacific Islander___%

   5. Other (please specify)_________________________________________

3. In general, what is the primary age range of your patient population?

   1. 0-18

   2. 19-35

   3. 36-64

   4. 65+

4. In general, what is the primary cost reimbursement method at your primary practice location?

   1. Private insurance

   2. Medicare/Medicaid

   3. Other (please specify)

5. How many years have you been in practice (post-residency or post-licensure)? _________

6. Do you have a role in training others to use medical devices?

   1. Yes

   2. No

7. What is your age? _______

8. What is your race/ethnicity?

   1. African American/Black

   2. Hispanic/Latino

   3. Caucasian/White

   4. Asian or Pacific Islander

   5. Other (please specify)

9. What is your gender?

   1. Male

   2. Female