Form #1 Form #1 Screening Questionnaire

A

Form Approved
OMB No. 0935-0179
Exp. Date 7/31/2014

ttachment A

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

1. Are you a health care provider (e.g. doctor, nurse, nurse practitioner, physician assistant)?

YES  CONTINUE

NO  TERMINATE

2. 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.

3. 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.

4. 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

5. 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

6. Are 25% or more of your patients uninsured, underinsured, or underserved?

Yes  CONTINUE (quota: at least half in this category)

No  CONTINUE

7. 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.

8. 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

9. 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

10. 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”

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11. What is your gender?

Male  CONTINUE

Female  CONTINUE

Attempt mix of genders

12. Are you Hispanic or Latino?

Yes  CONTINUE

No  CONTINUE

13. 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

14. How old are you?

Record: ______

Attempt mix of ages

END OF SCREENER