Cx3 Study - Initial Clinic Survey

Form Approved

OMB No. 0920-xxxx

Exp. Date: xx-xx-20xx

CDC’s Cervical Cancer Study (Cx3 Study)

Initial Clinic Survey – [month, 200x]

Your clinic is one of 18 Illinois clinics serving National Breast and Cervical Cancer Early Detection Program (NBCCEDP) patients that the Centers for Disease Control and Prevention (CDC) have selected for participation in CDC’s Cx3 Study. We would like you to complete this survey on behalf of your clinic. The survey is being conducted for CDC by the Battelle Centers for Public Health Research and Evaluation.

In this survey, we will ask you a series of questions regarding your clinic patient population, as well as the staff time associated with participating in the CDC Cx3 Study. The information provided by you and other clinics will provide valuable information to CDC to assist them in their efforts to provide cervical cancer screening to NBCCEDP women.

Key points:

• This survey has been sent to each of the 18 clinics participating in the Cx3 Study. We need responses from every clinic to make this important study valid.

• You will be asked to complete a similar survey each month for the next year.

• All information provided will be kept private and will not be disclosed to anyone except the researchers conducting the study. Responses will be reported only in summary form, combined with responses from the other participating clinics.

• Battelle will maintain a tracking file to link names with participant ID numbers for tracking survey mailings and linking your responses to all follow-up surveys. Once data collection is complete, the tracking file will be destroyed and there will be no way to link responses to you.

• The survey will take approximately 2 hours to complete.

When you have completed the survey, please return it in the enclosed postage-paid envelope to: CDC Cervical Cancer Study, 6115 Falls Rd, Suite 200, Baltimore, MD 21209-2219.

Thank you for your participation in this important study.

Public reporting burden of this collection of information varies from 1 to 3 hours with an estimated average of 2 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining 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)

Section A: Patient and Practice Characteristics

This section includes questions that will allow us to describe the clinics and patients that are participating in the Cx3 study. If you do not have an exact answer, please give us your best estimate. Please write in or check () your response.

1. During [month], how many patients were seen by all clinic providers? ______________

2. During [month], how many female patients age 18 and older were seen by all clinic providers? _____________

3. Of the female patients age 18 and older seen during [month], approximately how many were seen for annual health maintenance or “well-woman” exams? ______________

4. Please estimate what percentage of your female patients use the following payment methods:

Private medical insurance (including Managed Care) _______ %

Medicaid (including Medicaid Managed Care) _______ %

Medicare (including Medicare Managed Care) _______ %

Military (e.g., TriCare, other payors) _______ %

No insurance/self pay _______ %

Illinois Breast and Cervical Cancer Program (BCCP) _______ %

Other method (specify) ________________ _______ %

5. What percent of your female clinic patients are in each age group? (If you see no female patients in a particular age group, enter ‘0’)

Under age 13 _______ %

Age 13-17 _______ %

Age 18-50 _______ %

Age 51-65 _______ %

Over age 65 _______ %

Total 100%

6. What percent of your female patients are of Hispanic or Latina origin?

_______ %

7. What percent of your female patients are:

White _______ %

Black, African or African American _______ %

American Indian or Alaska Native _______ %

Asian _______ %

Native Hawaiian or Pacific Islander _______ %

Other (including multiracial) _______ %

Total 100%

8. Which of the following methods does the clinic currently use to remind patients when they are due for their next Pap test/cervical cancer screening? (Check all that apply)

a. Verbal prompts by physicians or other staff members during an office visit	
b. Reminders sent by U.S. mail	
c. Reminder telephone calls	
d. Reminders by email	
e. Personalized web page	
f. Other mechanism (specify): __________________________________________________	
g. No reminders are used	
h. Don’t know	

9. Which of the following methods does the clinic currently use to remind patients when they are due for follow-up for abnormal cytology? (Check all that apply)

a. Verbal prompts by physicians or other staff members during an office visit	
b. Reminders sent by U.S. mail	
c. Reminder telephone calls	
d. Reminders by email	
e. Personalized web page	
f. Other mechanism (specify): __________________________________________________	
g. No reminders are used	
h. Don’t know	

10. Which of the following methods does the clinic currently use to remind patients when they are due for follow-up for a positive HPV test? (Check all that apply)

a. Verbal prompts by physicians or other staff members during an office visit	
b. Reminders sent by U.S. mail	
c. Reminder telephone calls	
d. Reminders by email	
e. Personalized web page	
f. Other mechanism (specify): __________________________________________________	
g. No reminders are used	
h. Don’t know	

Section B: Cost for HPV DNA Test Implementation

1. During [month], how much total time did staff members spend on activities related to HPV DNA testing? In answering this question, we would like you to separate overall staff time according to whether it was primarily related to training, patient testing, or fulfilling requirements of the evaluation.

	TRAINING Include time spent to learn or review information about the HPV DNA test such as clinical guidelines for its usage, CME activities, and learning the procedures for handling test specimens		PATIENT TESTING Include time required to administer the HPV test, ship the tests to the CDC HPV lab, report test results to patients, and educate and counsel patients regarding test results.		EVALUATION ACTIVITIES Include time spent obtaining patient consent, entering data in the Web STAR system, administering the baseline survey to patients, and completing the provider and clinic surveys.
	No. of staff	No. of hours	No. of staff	No. of hours	No. of staff	No. of hours
a. Physician
b. Nurse practitioner
c. Physician assistant
d. Clinic manager or assistant manager
e. Registered nurses
f. Licensed practical nurse
g. Nursing Assistants
h. Other, please specify, __________
i. Other, please specify, __________
j. Other, please specify, __________
TOTAL

THANK YOU FOR YOUR PARTICIPATION IN THIS SURVEY. PLEASE MAIL THE SURVEY IN THE POSTAGE PAID ENVELOPE.

Attachment C1. Initial clinic survey 5