Provider-Based Recruitment Questionnaire_20101222

Provider-Based Recruitment Schema Questionnaire

Target: Provider

OMB Control Number: 0925-0593

OMB Expiration Date: July 13, 2013

Recruitment Strategy Substudy

Event Name(s):

Provider-Based Recruitment Schema Questionnaire (PB)

Instrument Name(s) and Versions:

Provider-Based Recruitment Schema Questionnaire (PB) – 1.0

Recruitment Groups:

Provider-Based

Interviewer-Completed

Date	Version	Document History
12/8/10	Minimal Data Set_PRiNCeS_UNC_1203	Original version
12/10/10	Provider-Based Recruitment Questionnaire_20101210	Formatted PBR document; added comment to OMB requesting advice regarding questions estimating race / ethnicity by observation; small modification to race categories to approximate OMB guidance.
12/14/2010	Provider-Based Recruitment Questionnaire_20101214	Made changes to race/ethnicity characteristics per OMB conversation on 12/13/2010
12/15/10	Provider-Based Recruitment Questionnaire_20101215	Jen edited OMB race/ethnicity questions per web guidance on observed/reported race/ethnicity.
12/15/10	Provider-Based Recruitment Questionnaire_20101215a	Review by J. Slutsman – no changes made
12/16/10	Provider-Based Recruitment Questionnaire_20101216	Reviewed by J. Graber, no changes made, but recommended sending to B. Haugen for variables to be completed by S3
12/22/10	Provider-Based Recruitment Questionnaire_20101222	Modified Part B Question 4 based off of Dr. Hirschfeld’s recommendation to include tracking medical specialty
12/22/10	Provider-Based Recruitment Questionnaire_20101222	Jen harmonized response categories for items 11 and 12 with item 10, per OMB guidance.

TABLE OF CONTENTS

Interviewer-Completed

INSTITUTION LEVEL OF THE PRACTICE 4

INDIVIDUAL PRACTICE LOCATION 5

Date Questionnaire is Completed: ____month_____day______year

Part A. Questions 1 through 6 are to be answered at the Institutional Level of the Practice.

Interviewer: Circle information sources used to complete instrument. Mark all that apply.

Observation Web site / printed info Interview with provider Interview with provider staff

Medical Practice Institution

1. N

   P

   ame of practice :_________________________________________________

2. P ractice number (PSU#, practice #)………………….........

3. H ow many practice locations?: ……………………………

4. How many total providers?...........................................

5. Does practice participate in research studies? Y N

If 5 yes, what type of research does practice participate in?

1. Pharmaceutical Y N

2. Practice-based research networks Y N

3. Other Y N

If c yes, specify: ___________________________________________________________

6. Were there special requirements for the medical practice to participate in NCS? Y N

If 6 yes, what was required?

1. Memorandum of understanding or other written partnership agreement Y N

2. Lease agreement Y N

3. Payment for staff time Y N

4. IRB Y N

5. Continuing Education Y N

6. Other incentive type of activities Y N

If f yes, specify:____________________________________________________________

Date Questionnaire is Completed: ____month_____day______year

Part B. Questions 1 through 24 are to be gathered for the Individual Practice location .

Interviewer: Circle information sources used to complete instrument. Mark all that apply.

Observation Interview with provider Interview with provider staff

Medical Practice Characteristics

1. Practice location address __________________________________________________________

P

L

2. Practice location number (PSU#, practice #,location #)…………

3. Practice location size (number of providers):……………………………………

4. Practice location provider mix (number of each provider type)

O bstrectrics/Gynocology (OB/GYN)

F amily Practice

Midwives

Other

5. What type of practice? Private with no health system or university affiliation

Private with health system or university affiliation

Health system with no university affiliation
Academic medical center
Federally qualified health center
Public health department clinic

Other, List:________________________________

6. Services provided: (choose all that apply) Pregnancy screening only

Prenatal care only

Full OB with birthing

GYN only/no OB

Other. List:_________________

7. Primary Hospitals (Hospital numbers –PSU#, specific hospital #) used for deliveries:

a

H

.___________________________________________................................

H

b.___________________________________________................................

c

H

.___________________________________________................................

d

H

. __________________________________________................................

e

H

.___________________________________________...............................

C haracteristics of Patients in Medical Practice

7. Number of births per month……………………………………………………

8. N umber of new prenatal patients per month…………………………………

9. Observed or reported primary race of patients:

American Indian or Alaska Native 0-33% 34-66% 67-100%

Asian 0-33% 34-66% 67-100%

Black or African American 0-33% 34-66% 67-100%

Hispanic or Latino 0-33% 34-66% 67-100%

Native Hawaiian
or Other Pacific Islander 0-33% 34-66% 67-100%

White 0-33% 34-66% 67-100%

7. Observed or reported primary language preferred by patients?

English 0-33% 34-66% 67-100%

Spanish 0-33% 34-66% 67-100%

Other 0-33% 34-66% 67-100%

If other, specify language ___________________________________________________________

7. Approximate payer mix :

Tricare 0-33% 34-66% 67-100%

Medicaid 0-33% 34-66% 67-100%

Commercial 0-33% 34-66% 67-100%

HMO 0-33% 34-66% 67-100%

Self Pay 0-33% 34-66% 67-100%

Description of Practice Location’s Participation in NCS

7. Allows NCS staff to provide training for office staff regarding the study? Y N

7. Allows NCS information to be displayed in waiting room? Y N

7. Allows NCS information to be displayed in exam rooms? Y N

7. Allows NCS staff to access patient records for eligibility determination? Y N

7. Office staff utilizes the Address Lookup Tool for eligibility determination? Y N

7. Allows us to send letter to patients to introduce NCS? Y N

7. Allows provider’s names to be used in the letter sent by NCS to introduce study? Y N

7. Provides patient information on NCS during the appointment? Y N

7. Allows an NCS staff person to speak with a patient during her appointment? Y N

7. Refers patients to NCS with no on-site contact? Y N

7. Other participation in NCS Y N

Specify:_________________________________________________________________________

Public reporting burden for this collection of information is estimated to average 10 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0593*). Do not return the completed form to this address.