Form 2 NAMCS-201 Community Health Center Induction Interview (L

OMB No. 0920-0234
FORM NAMCS-201
(10-28-2009)

START WITH NUMBER

U.S. DEPARTMENT OF COMMERCE

1. LABEL

Economics and Statistics Administration

U.S. CENSUS BUREAU
ACTING AS DATA COLLECTION AGENT FOR THE

U.S. Department of Health and Human Services
Centers for Disease Control and Prevention
National Center for Health Statistics

"Start With" Number Selection
To determine the "Start With" (SW) number, find the range in the left column that contains the TE number (page
6, line 48). Then, reading to the right, choose the first number that is between 1 and the TE number. If there are
no numbers in the row that are between 1 and the TE number, SKIP to the next row. This is your SW number.
Record the SW number below and on page 6, line 49. Also enter the SW number into first "Cumulative Visit
Number" row in Sampling Instruction 9 and complete the other two row entries.
With a TE
between

COMMUNITY HEALTH CENTER
INDUCTION INTERVIEW
2010
NOTICE – Public reporting burden of this collection of
information is estimated to average 20 minutes per
response, including 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 Information Collection Review Office, 1600
Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA
(0920-0234).

Use the 1st number in the row that is between 1 and the TE

1–99
100–199
200–299
300–399
400–499

b. CHC ID No.

a. Regional Office

c. Reporting Period
d. Community health center name and address

Provider ID

Name

Address

600–1,299
1,300 or more contact HQ

}

Start With Number

3. CHC CONTACT INFORMATION

Go to page 6, line 49.

NOTES

a. Name

c. Contact’s
telephone number

Area code + Number

b. Title

d. Fax
number

Area code + Number

4. FIELD REPRESENTATIVE INFORMATION
a. Telephone screener name

FR code

b. CHC Induction

FR code

5. RECORD OF TELEPHONE CALLS
Call

Date

Time

Results
a.m.
p.m.
a.m.
p.m.
a.m.
p.m.
a.m.
p.m.
a.m.
p.m.

1.
2.
3.
4.
5.

6. FINAL OUTCOME OF CHC SCREENING

Page 8

FORM NAMCS-201 (10-28-2009)

Appointment made ➝

Day of week

Time

1
2

Noninterview

Place

Date

USCENSUSBUREAU

1

Yes

2

No – SKIP to
Item 3

Assurance of confidentiality – All information which would permit
identification of an individual, a practice, or an establishment will be held
confidential, will be used for statistical purposes only by NCHS staff,
contractors, and agents only when required and with necessary controls,
and will not be disclosed or released to other persons without the
consent of the individual or establishment in accordance with section
308(d) of the Public Health Service Act (42 USC 242m) and the
Confidential Information Protection and Statistical Efficiency Act
(PL-107-347).

2. PROVIDER(S) SAMPLED IN LAST YEAR’S PANEL

500–599

e. Returning
CHC

SAMPLING INSTRUCTIONS (Continued)

7. INTRODUCTION
Hello (Name of respondent), I am (Your name). I’m calling for the Centers for Disease Control and Prevention
regarding their study of ambulatory care. You should have received a letter from the Director of the National
Center for Health Statistics, explaining the study. You have probably also received a letter from the U.S. Census
Bureau. We are acting as the data collection agents for the study.

7. The first provider to be selected for sampling will be the one who has the first "Cumulative visit
volume" greater than or equal to the SW number. Mark (X) in column f to indicate this selection.
8. The second sampled provider will have the first "Cumulative visit volume" that is greater than
or equal to the TE + SW. Mark (X) in column f to indicate this selection.
9. The third provider will have the first "Cumulative visit volume" greater than or equal to (TE*2)
+ SW. Again, mark (X) in column f to indicate this selection.

If CEO does not remember NCHS Letter –
The Centers for Disease Control and Prevention’s National Center for Health Statistics (NCHS) is
conducting the National Ambulatory Medical Care Survey (NAMCS). This annual study, which has
been in the field since 1973, collects information about the large portion of ambulatory care
provided by physicians and mid-level providers throughout the United States. Research utilizing
the NAMCS helps to inform physicians, health care researchers, and policy makers about the
changing characteristics of ambulatory health care in this country. In addition to the regular
sample of physicians, the NAMCS is once again specifically sampling providers from a national
sample of community health centers.

Cumulative Visit Volume
Critical Item Complete!

Complete the following table based on instructions 7 – 9 above.

Your center has been selected, and we are requesting a short interview (approximately 20
minutes) with you to obtain information that would allow us to sample three physicians or
mid-level providers in your health center. From these providers we will collect (1) information
from a sample of patient visits (e.g., demographics, diagnoses, services, and treatments), (2)
provider demographic and practice characteristics, and (3) information about cervical cancer
screening practices from providers who offer such services.
Many organizations and leaders in the health care community, including the one providing the
enclosed letter of endorsement, have expressed their support and join me in urging your
participation in this meaningful study. Participation is voluntary. The following are some key
points about the survey:
• Data collection for the NAMCS is authorized by Section 306 of the Public Health Service Act (Title
42, U.S. Code, 242k).

2

SW + TE

3

SW + (TE * 2)

Provider ID

Name

Address

Telephone No.

Expected
Visit
Volume

Final
disposition
from
NAMCS-1

1
2
3

FR Note- Keep in mind the following points:
• The first 3 digits of the Provider ID are the same as the first 3 digits of the CHC ID, the last digit is 1,
2, or 3 as listed above.
• Three NAMCS-1s are to be completed for each CHC regardless of CHC or provider disposition.

13. CHC FINAL DISPOSITION
1

3
4
5
6

FORM NAMCS-201 (10-28-2009)

SW

Selected Sample Providers

2

Page 2

1

Cumulative visit number

12. COMPLETE THE FOLLOWING TABLE BELOW FOR THE 3 SAMPLED PROVIDERS SELECTED.
COMPLETE A SEPARATE NAMCS-1 FOR ALL 3 ROWS BELOW.

• This study conforms to the Privacy Rule as mandated by HIPAA, because disclosure of patient
data is permitted for public health purposes, and the NCHS Research Ethics Review Board has
approved NAMCS.

A representative of the Census Bureau, acting as our agent, will be calling you to schedule an
appointment regarding the details of your participation. If you have any questions regarding your
participation, please call a NAMCS representative at (800) 392-2862. Additional information on the
survey may be obtained by visiting the NAMCS participant Web site at www.cdc.gov/namcs. We
greatly appreciate your cooperation.

The first "Cumulative visit
volume" equal to or greater than...

If this CHC was in last year’s sample (Item 1e), and any of the providers selected this year were
also selected last year (Item 2), choose the next provider on the list. If the provider is at the end of
the list, start at the top.
Reminder: Skip to the next provider if a provider is sampled who is expecting zero visits.

• All information collected will be held in the strictest confidence according to Section 308(d) of the
Public Health Service Act (42, U.S. Code, 242m(d)) and the Confidential Information Protection
and Statistical Efficiency Act (Title 5 of PL 107-347). This information will be used for statistical
purposes only. No patient names, social security numbers, or addresses are collected.

• U.S. Census Bureau employees, who administer the study, have taken an oath to abide by Title
13, U.S. Code, Section 9, which requires them to keep all information about your practice and
patients confidential.

Provider to be
Sampled

Completed Induction
Out-of-Scope (Rare, Please confirm disposition)
Refused-Breakoff
CHC not seeing patients during reporting week
Moved out of PSU (Rare, Please confirm disposition)
Can’t locate (Rare, Please confirm disposition)

FORM NAMCS-201 (10-28-2009)

}

Complete a NAMCS-1 for all 3 provider
IDs regardless of provider or CHC
disposition. If there are only 2 providers
at a CHC, you still would complete a
NAMCS-1 for the 3rd provider ID.

Page 7

8. CENTER CLASSIFICATION

11. SAMPLING PLAN (Continued)
Provider’s name

MD/DO, NP,
PA, NMW

Specialty

Expected visit
volume

Cumulative
visit volume

Mark (X) if to
be sampled

(a)

(b)

(c)

(d)

(e)

(f)

How would you classify this center? Mark (X) ALL that apply.
1

Federally-funded Community Health Center (330)
• Community Health Center (CHC)

36

• Migrant Health Center (MHC)

37

• Health Care for the Homeless (HCH)
• Public Housing Primary Care (PHPC) grant program

38
39
40
41

2

Federally Qualified Health Center, but not federally funded (330 look-alike)

3

Urban Indian (437) Health Center

4

None of the above – Read CLOSING STATEMENT below.

}

SKIP to item 9a.

CLOSING STATEMENT – Thank you, (Name of respondent), your center is not within the scope of this study.
We appreciate your time and interest. (Terminate interview and SKIP to item 12 on page 7.)

42
43

9. ADDRESS CONFIRMATION

44

a. We have your address as (Read item 1d). Is this correct?
1
Yes – SKIP to item 10
2
No, incorrect address – Ask item 9b

45
Total (Sum of lines 36–45) (From above)

b. What is the correct address and telephone number?
Total (Sum of lines 16–35) (From page 5)

Number and Street:
City:

Total (Sum of lines 1–15) (From page 4)

46

(Sum of lines 1–45)

47

Total Number of Providers

48

Divide the above Total Expected Visit Volume TOTAL by 3

49

= Total Expected
Visit Volume

State:

Zip Code:

Telephone number (Area code/Number/Ext.):

10. REVENUE SOURCES
START WITH number based on table on page 8

= TE
= SW

}

Go to
Instruction 7,
page 7.

Give FLASHCARD G (p.21 Flashcard Booklet) and ask:
What percent of your CHC’s revenue comes from the following sources?
Sources

Percentage

FR NOTE – If a particular provider does not expect to see patients during the sample week, include
them in the table above and place a zero in the “Expected visit volume (d)” column.
These providers should not be sampled.

330 Grant

%

Sampling Instructions –

Title V grant or contract

%

Other Federal Grant

%

State/Local Grant
Individual, corporation or
foundation grants or donations

%

Medicare/Medicaid

%

Patient fees

%

Other

%

1. Count the number of providers and enter in line 47.
2. Obtain an "Expected visit volume" for each provider (column d) for the sample week, keeping a
cumulative visit total in column e. If there are more than 45 providers continue the list on a
separate sheet and attach to this form.
3. The "Total expected visit volume" (line 46) should equal the last entry in "Cumulative visit volume",
column e.
4. If the community health center has 3 or fewer providers sample all providers. Go to
Instruction 12, page 7. If community health center has 4 or more providers then follow the rest
of these instructions.
5. Divide the "Total expected visit volume" by 3 (to one decimal place) – this is the Take Every
(TE) number. Place result into line 48.
6. To determine the "Start With" (SW) number: Refer to the table on page 8.
Page 6

FORM NAMCS-201 (10-28-2009)

%

FR NOTE – Categories should sum close to 100%. Do not leave blank or use dash to indicate 0 percent, include value.

Continue with item 11 on page 4.
FORM NAMCS-201 (10-28-2009)

Page 3

11. SAMPLING PLAN

11. SAMPLING PLAN (Continued)

I would like to discuss a plan for conducting the National Ambulatory Medical Care
Survey (NAMCS) to a sample of your providers. This center has been assigned to a
1-week reporting period that
begins on Monday,

MD/DO, NP,
PA, NMW

Specialty

Expected visit
volume

Cumulative
visit volume

Mark (X) if to
be sampled

(a)

(b)

(c)

(d)

(e)

(f)

16

.

and ends on Sunday,

Provider’s name

• I will need to sample 3 providers from your Center. In order to do this, I will need the name, specialty, and estimated
visit volume, corresponding to the sample week, for all physicians and mid-level providers at ALL IN-SCOPE
LOCATIONS. Please include all providers even if they do NOT plan on seeing patients during the sample week.
In-scope locations include all fixed locations that provide health care, including mobile clinics, and specialty clinics.
Please do not include providers that work solely at school-based clinics.
• Please exclude anesthesiologists, dentists, hygienists, optometrists, pathologists, psychologists, podiatrists, and
radiologists. Include physicians (both MDs and DOs), nurse practitioners (NPs), physician assistants (PAs), and nurse
midwives (NMWs).
• FR NOTE – If a particular provider does not expect to see patients during the sample week, include them in the table
below and place a zero in the “Expected visit volume (d)” column. These providers should not be sampled.
Item 11 table should include all in-scope locations. Providers, even if they do not expect to see patients
during the sample week, should be included; however, they should NEVER be sampled.
Provider’s name

MD/DO, NP,
PA, NMW

Specialty

Expected visit
volume

Cumulative
visit volume

Mark (X) if to
be sampled

(a)

(b)

(c)

(d)

(e)

(f)

17
18
19
20
21
22
23
24

1

25

2

26

3

27

4

28

5

29

6

30

7

31

8

32

9

33

10

34

11

35
Total (Lines 16–35) – Continue on next page.

12

➤

13
14
15

Continue with item 11, List of Physicians/Providers, on page 6.
Total (Lines 1–15) – Continue on next page.

➤

Continue with item 11, List of Physicians/Providers, on page 5.
Page 4

FORM NAMCS-201 (10-28-2009)

FORM NAMCS-201 (10-28-2009)

Page 5