Form 3.1 Survey

OMB Control Number: 0925-0593

OMB Expiration Date: 7/31/ 2013

Provider-Based Questionnaire, Phase II

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

Provider-Based Recruitment Schema Questionnaire (PB)

TABLE OF CONTENTS

INTERVIEWER-COMPLETED 3

INSTITUTION LEVEL OF PRACTICE 3

INDIVIDUAL PRACTICE LOCATION 5

Provider-Based Recruitment Schema Questionnaire (PB)

INTERVIEWER COMPLETED

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

(PB_INSTI_INFO_DATE) Date Questionnaire is Completed:

month________ day________ year _________

MM DD YYYY

(PB_INSTI_INFO_SOURCE) Interviewer: Circle information sources used to complete instrument. SELECT ALL THAT APPLY.

OBSERVATION………………………………………………………… 1

WEBSITE/PRINTED INFORMATION………………………………… 2

INTERVIEW WITH PROVIDER………………………………………. 3

INTERVIEW WITH PROVIDER STAFF……………………………… 4

Medical Practice Institution

1. (PB_INSTI_FULLNAME) Name of practice :_________________________________

2. (PB_INSTI_ID) Practice number (PSU#, Practice #)

|___|___|___|___|___|___|___|___| P |___|___|___|

PSU# PRACTICE#

3. (PB_INSTI_SIZE) How many practice locations?

|___|___|

TOTAL LOCATIONS

4. (PB_PROV_TOTAL) How many total providers?

|___|___|

TOTAL PROVIDERS

5. (PB_PRACT_RES) Does practice participate in research studies?

Yes……………………………………………………… 1

No………………………………………………………. 2 (PB_PRAC_SPEC)

If 5, (PB_PRACT_RES) = Yes, what type of research does practice participate in?

	YES	NO
Pharmaceutical (PB_RES_PHARM)	1	2
Practice-based research networks (PB_RES_NETWORK)	1	2
Other (PB_RES_OTH) IF YES, GO TO (PB_PRAC_RES _OTH)	1	2
(PB_PRAC_RES _OTH) SPECIFY ______________________________________________________________

6. (PB_PRAC_SPEC) Were there special requirements for the medical practice to participate in NCS?

Yes……………………………………………………… 1

No………………………………………………………. 2 (PROVIDER_COMPLETE_DATE)

If 6, (PB_PRAC_SPEC) = Yes, what was required?

	YES	NO
(PB_SPEC_MOU) Memorandum of understanding or other written partnership agreement	1	2
(PB_SPEC_LSE) Lease agreement	1	2
(PB_SPEC_PMT) Payment for staff time	1	2
(PB_SPEC_IRB) IRB	1	2
(PB_SPEC_CE) Continuing Education	1	2
(PB_SP_OTHINC) Other incentive type of activities. IF YES, GO TO (PB_INC_OTH)	1	2
(PB_INC_OTH) SPECIFY _________________________________________

INDIVIDUAL PRACTICE LOCATION

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

(PROVIDER_COMPLETE_DATE) Date Questionnaire is Completed:

month________ day________ year _________

MM DD YYYY

(PB_PROV_ SOURCE) Interviewer: Circle information sources used to complete instrument.

SELECT ALL THAT APPLY.

OBSERVATION………………………………………………… 1

INTERVIEW WITH PROVIDER………………………………. 2

INTERVIEW WITH PROVIDER STAFF……………………… 3

Medical Practice Characteristics

1. Practice location address.

_____________________________________________________

Street address (ADDRESS_1)/(ADDRESS_2)

___________________________ ________________________

Suite/Apt/Unit# (UNIT)………………City (CITY)

|___|___| |___|___|___|___|___| |___|___|___|___|

State Zip code Zip code+4

(STATE) (ZIPCODE) (ZIP4)

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

|___|___|___|___|___|___|___|___| P |___|___|___| L |___|___|

PSU# Practice# Location#

3. (PB_PROV_SIZE) Practice location size (number of providers)

|___|___|___|

Total providers

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

|___|___|

(NUM_OBGYN) Obstetrics/Gynecology (OB/GYN)

|___|___|

(NUM_FP) Family practice

|___|___|

(NUM_MIDWIVES) Midwives

|___|___|

(NUM_OTHER) Other

INTERVIEWER INSTRUCTION: VERIFY NUMBER OF OBGYNs, FPs, MIDWIVES AND OTHERS SUCH THAT (PB_PROV_SIZE) = (NUM_OBGYN) + (NUM_FP) + (NUM_ MIDWIVES) + (NUM_OTHER)

4. (PB_PRAC_TYPE) What type of practice?

Private with no health system or university affiliation 1

Private with health system or university affiliation …… 2

Health system with no university affiliation ……………… 3

Academic medical center ……………………………………4

Federally qualified health center …………………………… 5

Public health department clinic …………………………….. 6

Other,…………………………………………..……………… -5 (PB_PRAC_TYPE_OTH)

(PB_PRAC_TYPE_OTH), SPECIFY _______________________________________________

6. (PB_PROV_SVC) Services provided:

SELECT ALL THAT APPLY.

Pregnancy screening only…………………………………… 1

Prenatal care only ……………………………………………. 2

Full OB with birthing …………………………………………. 3

GYN only/no OB ……….…………………………………….. 4

Other. …………………………………………………………… -5 (PB_PROV_SVC_OTH)

(PB_PROV_SVC_OTH), SPECIFY _____________________________

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

1. Hospital #1 (INST_NAME1) (INSTITUTE_ID1) ________________________________

|___|___|___|___|___|___|___|___| H |___|___|___| Hospital name

PSU# Hospital#

2. Hospital #2 (INST_NAME2) (INSTITUTE_ID2) ________________________________

|___|___|___|___|___|___|___|___| H |___|___|___| Hospital name

PSU# Hospital #

3. Hospital #3 (INST_NAME3) (INSTITUTE_ID3) ________________________________

|___|___|___|___|___|___|___|___| H |___|___|___| Hospital name

PSU# Hospital #

4. Hospital #4 (INST_NAME4) (INSTITUTE_ID4) _________________________________

|___|___|___|___|___|___|___|___| H |___|___|___| Hospital name

PSU# Hospital #

5. Hospital #5 (INST_NAME5) (INSTITUTE_ID5) _________________________________

|___|___|___|___|___|___|___|___| H |___|___|___| Hospital name

PSU# Hospital #

Characteristics of Patients in Medical Practice

7. (NUM_BIRTHS) Number of births per month:

|___|___|

TOTAL BIRTHS

7. (NUM_NEW_PTS) Number of new prenatal patients per month:

|___|___|

TOTAL PATIENTS

7. Observed or reported primary race of patients:

(PT_RACE_AIAN) American Indian or Alaska Native:

0-33%.................................…………………………………… 1

34-66%..................……………………………………………. 2

67-100% …………….…………………………………………. 3

(PT_RACE_ASIAN) Asian:

0-33%.................................…………………………………… 1

34-66%..................……………………………………………. 2

67-100% …………….…………………………………………. 3

(PT_RACE_BLACK) Black or African American:

0-33%.................................…………………………………… 1

34-66%..................……………………………………………. 2

67-100% …………….…………………………………………. 3

(PT_RACE_HISP) Hispanic or Latino:

0-33%.................................…………………………………… 1

34-66%..................……………………………………………. 2

67-100% …………….…………………………………………. 3

(PT_RACE_NHPI) Native Hawaiian or Other Pacific Islander:

0-33%.................................…………………………………… 1

34-66%..................……………………………………………. 2

67-100% …………….…………………………………………. 3

(PT_RACE_WHITE) White:

0-33%.................................…………………………………… 1

34-66%..................……………………………………………. 2

67-100% …………….…………………………………………. 3

7. Observed or reported primary language preferred by patients?

(PT_LANG_ENG) English:

0-33%.................................…………………………………… 1

34-66%..................……………………………………………. 2

67-100% …………….…………………………………………. 3

(PT_LANG_SPAN) Spanish:

0-33%.................................…………………………………… 1

34-66%..................……………………………………………. 2

67-100% …………….…………………………………………. 3

(PT_LANG_OTH) Other:

0-33%.................................…………………………………… 1 (PT_LANG_SPEC)

34-66%..................……………………………………………. 2 (PT_LANG_SPEC)

67-100% …………….…………………………………………. 3 (PT_LANG_SPEC)

(PT_LANG_SPEC), specify language(s) ___________________________________________________________

7. Approximate payer mix :

(PAY_INS_TRICARE) Tricare:

0-33%.................................…………………………………… 1

34-66%..................……………………………………………. 2

67-100% …………….…………………………………………. 3

(PAY_INS_MEDICAID) Medicaid:

0-33%.................................…………………………………… 1

34-66%..................……………………………………………. 2

67-100% …………….…………………………………………. 3

(PAY_INS_COMM) Commercial:

0-33%.................................…………………………………… 1

34-66%..................……………………………………………. 2

67-100% …………….…………………………………………. 3

(PAY_INS_HMO) HMO:

0-33%.................................…………………………………… 1

34-66%..................……………………………………………. 2

67-100% …………….…………………………………………. 3

(PAY_SELF) Self Pay:

0-33%.................................…………………………………… 1

34-66%..................……………………………………………. 2

67-100% …………….…………………………………………. 3

Description of Practice Location’s Participation in NCS

	YES	NO
(PROVIDER_NCS_TRN) Allows NCS staff to provide training for office staff regarding the study?	1	2
(PROVIDER_NCS_INFOWT) Allows NCS information to be displayed in waiting room?	1	2
(PROVIDER_NCS_INFOEX) Allows NCS information to be displayed in exam rooms?	1	2
(PROVIDER_NCS_ACC) Allows NCS staff to access patient records for eligibility determination?	1	2
(PROVIDER_NCS_ALT) Office staff utilizes the Address Lookup Tool for eligibility determination?	1	2
(PROVIDER_NCS_LTR) Allows us to send letter to patients to introduce NCS?	1	2
(PROVIDER_NCS_PNLTR) Allows providers’ names to be used in the letter sent by NCS to introduce study?	1	2
(PROVIDER_NCS_INFO) Provides patient information on NCS during the appointment?	1	2
(PROVIDER_NCS_STF) Allows an NCS staff person to speak with a patient during her appointment?	1	2
(PROVIDER_NCS_RFR) Refers patients to NCS with no on-site contact?	1	2
(PROVIDER_NCS_PARTIC) Other participation in NCS. IF YES, GO TO (PROVIDER_NCS_OTH)	1	2
(PROVIDER_NCS_OTH), 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.