Telephone Screening Interview for Hospitals

Form Approved

OMB #0920-0743
Exp. Date: xx/xx/xxxx

Screening Telephone Call to Identify the Appropriate

Survey Respondent at Hospitals

A screening call will be made to all hospitals in the United States reporting in the most recent American Hospital Association Annual Survey, that they had at least one registered maternity bed. The screening calls will (1) confirm that the hospital is eligible for inclusion in the study, (2) determine whether or not the hospital has satellite locations that had registered maternity beds, and (3) obtain the name and address of the individual who is most knowledgeable about infant feeding practices at the hospital and/or satellite clinic. The screening survey will be administered as computer-assisted telephone interview. As a result, data entry will be performed as part of the interview process and the skip-logic will be electronic.

Call #1 to the operator/receptionist who answers the phone at the hospital.

1. Can you please connect me to the mother/baby manager?

Once connected:

Hello. My name is (INTERVIEWER NAME). I am calling on behalf of the Centers for Disease Control and Prevention. CDC is conducting a national survey of Maternity Practices in Infant Nutrition and Care. The survey is being sent to all hospitals and freestanding birth centers in the U.S. and Territories that routinely provide maternity care. I need to first confirm that this hospital provides maternity care.

2. Did your hospital have any registered maternity (Ob/Gyn) beds as of December 31, 2010?

• Yes

• No

If NO, conclude the interview by saying: “I’m sorry, but our study is focusing on maternity care. Thank you very much for your time.” If YES, continue with question 3.

Public reporting burden of this collection of information is estimated to average 5 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 CDC Reports Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0743). Do not send the completed form to this address.

2. Does the hospital have multiple locations that provide maternity care?

 Yes

• No

If NO, continue with question 6.

If YES, continue with question 4.

2. How many locations provide maternity care?

• one

• two

• three

• four

2. Could you please provide a contact and telephone number for each of the locations?

• Location 1: Telephone number_______________ Contact___________________

• Location 2: Telephone number_______________ Contact___________________

• NA

• Location 3: Telephone number_______________ Contact___________________

• NA

• Location 4: Telephone number_______________ Contact___________________

• NA

2. We will be mailing a survey to your facility. The survey includes questions about infant nutrition, such as breastfeeding, use of formula by healthy newborns, and feeding routines. I was hoping that you will be able to help me identify the best person to complete the survey. This may be yourself, or another person at the hospital. Please record the name and title of that person identified.

Name: _________________________________________

Title: _________________________________________

2. What is the Federal Express address, telephone number, and email address for [PERSON IDENTIFIED IN QUESTION 6]? Be sure that the address includes the name of the facility.

Name of facility: _________________________________________

Fed Ex address: _________________________________________

_________________________________________

City, State, Zip Code: _________________________________________

Telephone Number: _________________________________________

E-mail address: _________________________________________

2. Is the mailing address for Dr./Mr./Ms. [PERSON IDENTIFIED IN QUESTION 6] the same as his/her Federal Express address? If not, what is his/her mailing address?

Mailing address: _________________________________________

_________________________________________

City, State, Zip Code: _________________________________________

Conclude the interview by saying: “That is all the information I need at the moment. Thank you very much for your time and assistance. You have been very helpful. Good-bye.”

Call to additional locations of hospital providing maternity care.

Hello. My name is (INTERVIEWER NAME). I am calling on behalf of the Centers for Disease Control and Prevention. CDC is conducting a national survey of Maternity Practices in Infant Nutrition and Care. The survey is being sent to all hospitals and freestanding birth centers in the U.S. and Territories that routinely provide maternity care. We understand that this facility provides maternity care associated with (HOSPITAL IDENTIFIED in Question 7). I need to first confirm that this hospital provides maternity care.

2. Did this facility have any registered maternity (Ob/Gyn) beds as of December 31, 2010?

• Yes

• No

If NO, conclude the interview by saying: “I’m sorry, but our study is focusing on maternity care. Thank you very much for your time.” If YES, continue with question 10.

2. We will be mailing a survey to your facility. The survey includes questions about infant feeding such as breastfeeding, use of formula by healthy newborns, and feeding routines. I was hoping that you will be able to help me identify the best person at the facility to complete the survey. This may be yourself, or another person at the hospital. Please record the name and title of that person identified.

Name: _________________________________________

Title: _________________________________________

2. What is the Federal Express address, telephone number, and email address for [PERSON IDENTIFIED IN QUESTION 10]? Be sure that the address includes the name of the facility.

Facility Name: _________________________________________

Address: _________________________________________

_________________________________________

City, State, Zip Code: _________________________________________

Telephone Number: _________________________________________

E-mail address: _________________________________________

2. Is the mailing address for Dr./Mr./Ms. [PERSON IDENTIFIED IN QUESTION 10] the same as his/her Federal Express address? If not, what is his/her mailing address?

Mailing address: _________________________________________

_________________________________________

City, State, Zip Code: _________________________________________

Conclude the interview by saying: “That is all the information I need at the moment. Thank you very much for your time and assistance. You have been very helpful. Good-bye.”

Telephone Screening Interview – Hospitals Appendix G-1 page 5 of 5