A
Form
Approved
OMB No. 0935-0179
Exp. Date 7/31/2014
National Initiative for the Promotion of Evidence-Based Health Information
Health Professionals Awareness Campaign Concept Testing
Screening Questionnaire
FINAL 2.27.12
Segment |
Baltimore |
Atlanta |
Doctors* |
2 Segmented into one “open” and one “closed” group |
2 Segmented into one “open” and one “closed” group |
Physician Assistants/Nurse Practitioners* |
2 Segmented into one “open” and one “closed” group |
2 Segmented into one “open” and one “closed” group |
Nurses (RNs) |
1 |
1 |
Total |
5 |
5 |
Are you a health care provider (e.g. doctor, nurse, nurse practitioner, physician assistant)?
YES CONTINUE
NO TERMINATE
What type of health care provider are you?
Physician CONTINUE
Physician Assistant CONTINUE
Nurse Practitioner CONTINUE
Registered Nurse (RN) CONTINUE
Other TERMINATE
Public reporting burden for this collection of information is estimated to average 5 minutes per response, the estimated time required to complete the survey. 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: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.
What is your practice focus:
General practice CONTINUE
Internal medicine CONTINUE
Family practice CONTINUE
Pediatrics TERMINATE
Obstetrics/Gynecology TERMINATE
Other CHECK WITH RTI (see note, below; specialists are excluded)
Note to recruiter: We are looking for health care providers who are in general, internal or family practices ONLY. We are excluding those who work in specialties such as OB/GYN, pediatrics, or others.
For how many years have you been in practice (for physicians, time since finishing residency. For others, time since licensure)?
RECORD: _______
If less than 1 TERMINATE
If between 1-25 CONTINUE
If more than 25 TERMINATE
In what kind of setting do you practice?
Private or Group Practice CONTINUE but try for mix
Clinic CONTINUE but try for mix
Urgent Care CONTINUE but try for mix
Hospital-based or ambulatory clinic CONTINUE but try for mix
Other CONTINUE but try for mix
Are 25% or more of your patients uninsured, underinsured, or underserved?
Yes CONTINUE (quota: at least half in this category)
No CONTINUE
Do you access the internet or other online resource on a computer or via mobile technology (iPhone/iPad, Android, Blackberry, etc.) for professional use?
Yes CONTINUE
No TERMINATE
NOTE: QUESTIONS 8, 9, AND 10 ARE FOR PHYSICIANS, NURSE PRACTITIONERS, AND PHYSICIAN ASSISTANTS ONLY. NURSES SHOULD SKIP TO Q11.
When seeing a patient for a
regular checkup or follow up visit, how likely are you to refer him
or her to specific patient-information resources? Resources can be
defined as anything that provides additional information to patients
about the disease/condition and its possible treatments, including
brochures, printouts, or websites.
Very likely
CONTINUE but see
segmentation instructions
Somewhat likely CONTINUE but see segmentation instructions
Unlikely CONTINUE but see segmentation instructions
When diagnosing a patient with a
new condition, how likely are you to refer him or her to specific
patient-information resources?
Very likely
CONTINUE but see segmentation instructions
Somewhat likely CONTINUE but see segmentation instructions
Unlikely CONTINUE but see segmentation instructions
When seeing a patient for a
chronic condition, how likely are you to refer him or her to
specific patient-information resources?
Very likely
CONTINUE but see segmentation instructions
Somewhat likely CONTINUE but see segmentation instructions
Unlikely CONTINUE but see segmentation instructions
SEGMENTATION
INSTRUCTIONS using question 8-10:
If “very likely” to any one of three questions Classify as “open”
If “somewhat likely” to at least two questions Classify as “open”
Otherwise Classify as “closed”
What is your gender?
Male CONTINUE
Female CONTINUE
Attempt mix of genders
Are you Hispanic or Latino?
Yes CONTINUE
No CONTINUE
How would you best describe your race?
American Indian or Alaska Native CONTINUE
Asian CONTINUE
Native Hawaiian or Other Pacific Islander CONTINUE
Black or African American CONTINUE
White CONTINUE
Attempt mix of races
How old are you?
Record: ______
Attempt mix of ages
END OF SCREENER
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Peyton Williams |
File Modified | 0000-00-00 |
File Created | 2021-02-01 |