Attachment L- Three Week Postcard

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Attachment L:

Three-Week Postcard Reminder and Subsequent Postcard Reminders for Mail Survey Nonrespondents

[Dear X]:

We recently mailed you a survey about the Agency for Healthcare Research and Quality (AHRQ)’s assessment of the Emergency Severity Index (ESI), a triage tool used in emergency departments. If you have already completed and mailed back this survey, thank you for your participation. If you have not yet had the chance to complete your survey, we would appreciate your timely response.

If you would like to complete the survey online, please do so by visiting http://XXXXXXX. You may also complete the survey by phone, by calling 1-866-XXX-XXXX. Your participation in this study is critical to the success of this assessment, and will provide AHRQ with important information about the ESI tool.

If you have misplaced or lost your questionnaire and would like us to mail you another, would like to complete the survey in another form, or if you have any questions or concerns please email NORC at [email protected] or call toll free at 1-866-XXX-XXXX.

Thank you again for your participation in this very important study.

Bruce Siegel, MD, MPH

Research Professor, Department of Health Policy

The George Washington University

Daniel S. Gaylin, MPA

Executive Vice President for Health Research

NORC

Public reporting burden for this collection of information is estimated to average 20 minutes per response, the estimated time required to complete the survey. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.