Form unnumbered Att. T. Cervical Cancer Screening Supplement

Form Approval OMB No. 0920-0234

9.

As it relates to the HPV vaccine,
how often does your clinic –
Mark (X) only ONE for each row.
a. Use the number of sexual partners to
determine who should get the HPV
vaccine?

FORM NHAMCS-906
(1-30-2009)

Rarely or
never

Sometimes

Usually

Always or almost
always

2

3

4

5

b. Perform a Pap test to determine who
should get the HPV vaccine?

1

2

3

4

5

c. Recommend the HPV vaccine to
females with a history of an abnormal
Pap test result (ASC-US or higher)?

1

2

3

4

5

d. Recommend the HPV vaccine to
females with a positive HPV test?

1

2

3

4

5

11. How will this clinic determine when to start routine
cervical cancer screening for fully HPV vaccinated
females?

1
2
1

Mark (X) all that apply.

Economics and Statistics Administration

U.S. CENSUS BUREAU

Unknown/Not
applicable/
Do not ask

1

10. Will this clinic’s cervical cancer screening and
management procedures change for females who have
been fully vaccinated with the HPV vaccine?

U.S. DEPARTMENT OF COMMERCE
ACTING AS DATA COLLECTION AGENT FOR THE

U.S. Department of Health and Human Services
Centers for Disease Control and Prevention
National Center for Health Statistics

NATIONAL HOSPITAL AMBULATORY MEDICAL CARE SURVEY
2010 CERVICAL CANCER SCREENING SUPPLEMENT
NOTICE – Public reporting burden of this collection of information is estimated to average 15 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/ATSDR
Information Collection Review Office; 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0234).
Assurance of Confidentiality – All information which would permit identification of an individual, a practice, or an establishment will be held confidential, will
be used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released
to other persons without the consent of the indvidual or establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the
Confidential Information Protection and Statistical Efficiency Act (PL-107-347).

Yes
No – SKIP to item 14
By age
1
At same age as non-HPV
vaccinated females –
Specify age

BACKGROUND INFORMATION
B. Clinic type – Mark (X) only ONE.

A. Hospital number

1

At a later age –
Specify age
By onset of sexual activity –
How many year(s) since
onset of sexual activity?
Will not be screening fully HPV vaccinated females
Unknown
2

2

3
4

12. How often will this clinic routinely screen for cervical
cancer among females that have been fully vaccinated
with the HPV vaccine? Mark (X) one.

1
2
3
4
5
6

13. Will this clinic be using the HPV DNA test for
managing abnormal cytology for females that have
been fully vaccinated with the HPV vaccine?

1
2

14. Please indicate whether you agree with, disagree with, or are
unsure of the statements in a. and b.
a. There will be fewer numbers of abnormal Pap tests
among vaccinated females.
b. There will be fewer referrals for colposcopy among
vaccinated females.

D. Census contact name

INTRODUCTION

Annually
Every 2–3 years
Every 4–5 years
Greater than every 5 years
Will not be screening fully HPV vaccinated females
Unknown

1.

2

GM

Area code Number

E. Census contact
telephone

The Centers for Disease Control and Prevention is conducting a special survey on cervical cancer
screening performed in hospital outpatient clinics. Please answer the following questions. We
appreciate your time on this important public health concern.

Does this clinic use any of the following methods to screen for
cervical cancer?
Mark (X) all that apply.

Mark (X) one interval for routine screening.
Annually Every 2 Every 3
years
years

a. Conventional Pap test (Definition – Smear spread on glass slide and fixed)

Yes
No

1

Agree

Disagree

2

Unsure

3

Yes – How often does this clinic routinely screen women using this
method?
No
Continue with item 1b
Unknown

More
than 3
years

No
routine
interval
recommended

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

}

b. Liquid-based cytology (Definition – Specimen suspended in liquid solution)
1

2

3

1

2

3

1
2
3

15. The Centers for Disease Control and Prevention (CDC) funds state health departments to provide breast and cervical
cancer screening services to low income women through the National Breast and Cervical Cancer Early Detection
Program (Title XV). The state health departments contract out the screening services to physicians and other health
care providers. Is this clinic currently participating in this state or national screening program?
1
Yes 2 No 3 Unknown
16. For purposes of this survey, which of the following categories describe your profession? – Mark (X) only ONE.
Physician assistant/
3
Registered nurse
4
Other clinic staff
1
Physician
2
Nurse practitioner/ Nurse midwife

1
2
3

2.

3

FORM NHAMCS-906 (2-6-2009)

}

Yes – How often does this clinic routinely screen women using this
method?
No
Unknown

Does this clinic perform colposcopy?
2

Thank you for completing this special survey. We appreciate your time and cooperation.

Yes – How often does this clinic routinely screen women using this
method?
No
Continue with item 1c
Unknown

c. Other – Specify

1

CLOSING STATEMENT

Page 4

OB/GYN

C. AU number

Yes
No
Unknown

USCENSUSBUREAU

3a. Does this clinic ever order or collect the Human
Papillomavirus (HPV) DNA test?
Yes – Go to item 3b
No – SKIP to item 3c
Not aware of HPV DNA test
Unknown

1
2
3
4

}

SKIP to item 9
on page 4

b. Which of the following HPV DNA tests are ordered or
collected in this clinic? Mark (X) all that apply.
High risk (HR) HPV DNA test
Low risk (LR) HPV DNA test
Not aware there was a high risk or
low risk HPV DNA test
Type-specific HPV DNA test
Unknown

1
2
3
4
5

}

2

3

1
2
3

SKIP to
item 4a

c. Why is the HPV DNA test not ordered or collected in
this clinic? – Mark (X) all that apply.
1

4a. If a patient’s Pap test result is borderline or abnormal,
does this clinic routinely order an HPV DNA test to be
performed on that sample (commonly called reflex
HPV DNA testing)? (An HPV DNA test may be run on
the same liquid-based medium as the Pap test or an
HPV DNA test specimen may be collected at the
same time as the conventional Pap test.)

This clinic does not see the types of patients for
whom the HPV DNA test is indicated.
This clinic uses other tests, procedures, or
examination methods to manage patients for whom
the HPV DNA test is indicated.
The patients in this clinic have timely access to
colposcopy.

The labs affiliated with this clinic do not offer the
HPV DNA test.

2

6

The health plans or health systems affiliated with
this clinic do not recommend the HPV DNA test.

4

7

The HPV DNA test is not a reimbursed or covered
service for most patients in this clinic.

Notifying or counseling patients about positive HPV
DNA test results would take too much time.

1

3

11

Notifying or counseling patients about positive HPV
DNA test results might make clinicians in this clinic
feel uncomfortable.
Notifying or counseling patients about positive HPV
DNA test results might make patients in this clinic
feel uncomfortable, angry, or upset.
SKIP to item 7 on page 3.

1

3

2

4
5
6

7.

1

Women under 21 years old
Women 21 years old to 29 years old
Women 30 years old and over
Other – Specify

Yes – Go to item 5b
No
SKIP to item 6a on page 3
Unknown

}

2

4

5

ASC-US (atypical squamous cells of
undetermined significance)
ASC-H (atypical squamous cells of undetermined
significance – cannot exclude high-grade
intraepithelial lesion)
LSIL (low-grade squamous intraepithelial lesion,
encompassing mild dysplasia/CIN1)
HSIL (high-grade squamous intraepithelial lesion,
moderate dysplasia/CIN2, severe dysplasia/CIN3,
and carcinoma in situ)
AGC (atypical glandular cells)
FORM NHAMCS-906 (2-6-2009)

Given the following screening histories, when would this clinic recommend that a woman between 30 and 60
years of age return for her next Pap test?

Prior Pap test results
in past 5 years
(excluding current
normal results)

b. For which abnormal or borderline Pap test result would
this clinic recall a patient for an HPV DNA test?
Mark (X) all that apply.

3

Page 2

Women under 21 years old
Women 21 years old to 29 years old
Women 30 years old and over
Women who request the test for cervical cancer screening
Women who request the test to check their HPV infection status
Other – Specify

1

5a. Does this clinic routinely recall patients to come back for a
second sample collection for an HPV DNA test if their Pap
test is abnormal or borderline (recall testing)?

2
10

3

}

c. For which patients does this clinic usually order reflex
HPV DNA testing? – Mark (X) all that apply.

5

9

}

2

3

Assessing patients’ HPV infection status is not a
priority at this clinic.

Discussing cervical cancer screening in the context
of an STD is avoided in this clinic.

Yes – Go to item 6b
No
SKIP to item 7
Unknown

1

b. For which patients does this clinic routinely order or collect an HPV DNA test along with the Pap test (commonly called
adjunct HPV testing or cotesting)? Mark (X) all that apply.

Yes – Go to item 4b
No
SKIP to item 5a
Unknown

b. For which borderline or abnormal Pap test result would
this clinic order or collect a reflex HPV DNA test?
Mark (X) all that apply.
1
ASC-US (atypical squamous cells of undetermined
significance)
2
ASC-H (atypical squamous cells of undetermined
significance – cannot exclude high-grade
intraepithelial lesion)
3
LSIL (low-grade squamous intraepithelial lesion,
encompassing mild dysplasia/CIN1)
4
HSIL (high-grade squamous intraepithelial lesion,
moderate dysplasia/CIN2, severe dysplasia/CIN3,
and carcinoma in situ)
5
AGC (atypical glandular cells)

4

8

6a. Does this clinic routinely order or collect an HPV DNA test at the same time as the Pap test as part of routine cervical
cancer screening (commonly called adjunct HPV testing or cotesting)?

For each of the following scenarios, mark (X) only ONE for each row.
Have no
Current
Current
experience
HPV
No
6
months
3
1
2
with this
DNA test Pap test follow-up Less than
to less
years
year
years
6 months
type of
result
results
needed
than 1 year
or more
patient or
test

(a) Two consecutive
normal Pap tests

Has not
had test

Normal

1

2

3

4

5

6

7

(b) Two consecutive
normal Pap tests

Negative

Normal

1

2

3

4

5

6

7

(c) Two consecutive
normal Pap tests

Positive

Normal

1

2

3

4

5

6

7

(d) Has not had a Pap
Negative
test

Normal

1

2

3

4

5

6

7

(e) Has not had a Pap
test

Positive

Normal

1

2

3

4

5

6

7

(f) Abnormal Pap test Negative

Normal

1

2

3

4

5

6

7

(g) Abnormal Pap test

Normal

1

2

3

4

5

6

7

Positive

QUESTIONS 8–14 ASK ABOUT THE HPV VACCINE
8.

How often does this clinic use an HPV test to determine who should get the HPV vaccine? Mark (X) only one.
1
2
3
4
5

Rarely or never
Sometimes
Usually
Always or almost always
Do not recommend the HPV vaccine –SKIP to item 10.

FORM NHAMCS-906 (2-6-2009)

Page 3