Form #2 Screening Questionnaire

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

ATTACHMENT B

Screening Questionnaire

Summary of recruiting specifications

Health care practitioner/Clinician (list to be obtained from TEP and other resources) who is involved in helping patients make clinical care/treatment decisions

Group 1: Health care practitioners only involved in educating patients and caregivers about treatment/intervention options (e.g., Nurses, Pharmacists, Certified Health Educator Specialists, Care Coordinators, etc.).

Group 2: Health care practitioners involved in educating patients and caregivers about treatment/intervention options; also engaging the patient/caregiver in the process shared decisionmaking and responsible for prescribing, diagnosing and/or delivering treatment/intervention (e.g., Physician, Physician Assistant, Nurse Practitioner).

1. What type of health care practitioner are you? (Check all that apply)

• Physician, generalist

• Physician, specialist

______________________ (Please specify specialty)

• Physician assistant

• Nurse practitioner

• Registered nurse (RN)

• Pharmacist

• Clinical psychologist

• Clinical social worker

• Care manager/case manager

• Certified health educator

• Certified diabetes educator

• Health care navigator/patient navigator

• Respiratory therapist

• Registered dietician

• Other
  ______________________ (Please specify)

2. If you selected more than one health practitioner category above, which role do you most closely identify with as a patient educator?

Please specify: ___________________________________________

Public reporting burden for this collection of information is estimated to average 1 minute 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. In what kind of setting do you practice? (aim for a mix of settings)

• Ambulatory/office-based care setting

• Behavioral health care setting

• Community health care setting

• Federally qualified health center/public

• Home care

• Hospital-based setting

• Long term care facility

• Pharmacy setting

• Rural health care center

• Substance use/abuse treatment center

• Other______________________ (Please specify)

4. Do you diagnose and treat illness, order and interpret tests, and/or write prescriptions as part your regular job responsibilities? (to distinguish between Group 1 and Group 2)

• Yes

• No

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

• Yes (quota: at least half in this category)

• No

6. Are you familiar with the approach of shared decisionmaking in healthcare?

• Yes

• No

7. Do your regular job responsibilities include:

	Yes	No
Educating patients and/or their caregivers about their treatment or intervention options?		
Assisting patients and/or their caregivers with how to interpret and take advantage of information regarding available options for treatment/interventions?		
Assisting patients in making decisions about treatment or other interventions (e.g., screening or diagnostic) related to their health conditions?		
Educating/training other practicing or future clinicians?		

Inclusion Criteria (1 or more of the following)

• Educating patients and/or their caregivers about their treatment or intervention options?

• Assisting patients and/or their caregivers with how to interpret and take advantage of information regarding available options for treatment/interventions?

• Assisting patients in making decisions about treatment or other interventions (e.g., screening or diagnostic) related to their health conditions?

• Educating practicing or future clinicians?

Inclusion Criteria for Group 2

• One or more of the above, AND,

• Job responsibilities that include diagnosing and/or treating illness, ordering intervention, and/or writing prescriptions.

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