Screener

Form Approved

OMB No. 0920-0840

Expiration Date 01/31/2013

Usability Study of Medscape’s Technology-Based Panel

Medscape Screener Questionnaire

Public reporting burden of this collection of information is estimated to average 3 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: OMB-PRA (0920-0840)

1. How many years have you been practicing medicine? ______________

< 2		TERMINATE
2 or >		 CONTINUE

2. What is your specialty?

Primary Care/ Family Medicine		 CONTINUE
Internal Medicine		 GO TO Q3A-Q3B
Infectious Disease		 CONTINUE
Other		TERMINATE

ASK INTERNAL MEDICINE DOCTORS ONLY

3A. Do you have a sub-specialty?

Yes _____  Go to Q3B

No _____  CLASSIFY AS PCP AND CONTINUE

3B. What is your sub specialty? _____________________________________

[Check all that apply]

• Adolescent medicine

• Allergy and immunology

• Cardiology

• Endocrinology

• Gastroenterology

• Geriatrics

• Hematology

• Infectious disease

• Nephrology Oncology

• Pulmonology

• Rheumatology

• Sports medicine

• Other: ___________________

[IF INFECTIOUS DISEASE - CLASSIFY AS INFECTIOUS DISEASE

AND CONTINUE]

[IF ANYTHING ELSE, TERMINATE ]

4. In which of the following settings do you have your largest patient load?

[CHECK ALL THAT APPLY]

Private practice (By private practice, we mean a private physician’s office or group practice.)
Public clinic
Hospital
Academic-based

4. Of all the patients that you see, what percentage of your patients do you see in a private practice?

Private practice

%

[FOR IDs -- MUST BE 50% OR TERMINATE]

[FOR PCPs – MUST BE 50% OR TERMINATE]

6. Thinking about your current caseload, about what percentage of the patients that you regularly see in your practice are 13- to 64-years-old?

________________%

[FOR PCPs –TERMINATE IF LESS THAN 50]

6. Thinking about your current caseload, how many of the patients that you regularly see in your practice are living with HIV or AIDS?

________________

[FOR IDs -- MUST BE “50” OR GREATER TO QUALIFY FOR PIC SAMPLE]

[FOR PCPs –TERMINATE FROM PIC SAMPLE IF LESS THAN 20]

[CONTINUE TO CHECK ELIGIBILITY FOR HSSC SAMPLE AMONG THOSE EXCLUDED FROM PIC SAMPLE]

6. What is the name of your (practice, hospital, clinic, or HMO system)?

___________________________________

6. What is the postal zip code where you primarily practice?

Six- eight digits
Refused

[FOR HSSC, ZIP CODE MUST BE IN DESIGNATED MARKET AREA FOR ONE OF FIVE IMPLEMENTATION CITIES (Atlanta, Baltimore, Miami, New York, and Philadelphia) TO QUALIFY]

[ALL ZIP CODES ELIGIBLE FOR PIC]

6. Please tell me your age. _____________

7. Gender

Male
Female