Form #1 Form #1 Screening and Demographics Questionnaire

Attachment B: Screening Questionnaire

Script to be used when speaking with individuals by telephone

who have responded to an announcement to participate

in the Health IT Tool Evaluation project.

If responding to an incoming call.

Thank you for contacting us. My name is [Name] from Mosaica Partners. We are leading recruitment and enrollment for this AHRQ-funded study. The purpose of this telephone call is to determine if you have the background and experience we’re seeking for this study. If you do, you will be added to our list of qualified candidates. From that list, we will invite individuals to participate in an individual or group interview session -- which I’ll explain further in a few minutes.

We anticipate inviting all individuals who qualify for the evaluation but there is no guarantee that you will actually be selected to participate. If you are selected to participate, you will be provided an honorarium payment of $75 to compensate you for your time.

Can we proceed?

How did you hear about this study?

Example: A friend, a flyer on our company bulletin board, email distribution, etc.

Probe for specific information.

That’s great. In case we’re interrupted, let me get your contact information before we go any further.

Collect name, title, company, telephone number, and email contact information.

If responding to an incoming email (assuming have a telephone number for contact).

Thank you for contacting us. My name is [Name] from Mosaica Partners. We are leading recruitment and enrollment for this AHRQ-funded study. The purpose of this telephone call is to determine if you have the background and experience we’re seeking for this study. If you do, you will be added to our list of qualified candidates. From that list, we will invite individuals to participate in an individual or group interview sessions -- which I’ll explain further in a few minutes.

We anticipate inviting all individuals who qualify for the evaluation but there is no guarantee that you will actually be selected to participate. If you are selected to participate, you will be provided an honorarium payment of $75 to compensate you for your time.

Can we proceed?

How did you hear about this study?

Example: A friend, a flyer on our company bulletin board, email distribution, etc.

Probe for specific information.

That’s great. Let me make sure I have your contact information before we go any further:

Ensure you have name, title, company, telephone number and email contact information.

Gather information on subject’s background and experience.

Our announcement indicated we’re seeking either researchers or implementers with hands-on experience in evaluating health IT systems. Do you feel this accurately describes you?

If Yes: Great. Would you say you are primarily a researcher or an implementer?

If No: We apologize for the miscommunication. Unfortunately, we will not be able to include you in our study at this time. Thank you for willingness to participate in our study. We would appreciate your referral to a friend or colleague who is either a researcher or implementer of health IT systems.

Can you briefly describe your experience as a researcher or implementer of health IT systems? For example, on what type of systems have you worked and what was your role?

If subject’s background and experience IS appropriate

Based on the information you have provided, it seems like you have the type of background and experience we’re seeking. Is this something in which you would like to participate?

If subject’s background and experience IS appropriate, then proceed to describe the research study and process.

If subject’s background and experience IS NOT appropriate:

Thank the subject for their time. Tell them their inquiry will be confidential and that the contact information they have provided will not be used for any other purpose.

If subject’s background and experience is appropriate, then proceed to describe the research study and process.

Let me tell you about the study.

The Agency for Healthcare Research and Quality (AHRQ) has contracted with Westat and Mosaica Partners to conduct an evaluation to help the help AHRQ in their efforts to provide access to the best possible collection of information and tools related to the evaluation of health IT research and implementation.

As an experienced researcher or implementer, AHRQ would like to know your thoughts about what kinds of information and tools would be useful, and what you would like to see in specific tools.

We take the privacy of participants in this research study seriously. Generally, only summary data will be provided to AHRQ. The names of individual participants will not be provided to AHRQ. Your responses will be kept confidential to the extent permitted by law, including AHRQ’s confidentiality statute, 42 USC 299c-3(c). Any verbatim quotes we include in our report to AHRQ will not be attributed to a specific individual.

We will conduct individual and group telephone interviews, which will be scheduled within the next XX days. They will be led by an experienced facilitator from either Mosaica Partners or Westat. The interviews will make use of an online collaboration tool, and should last between 60 and 90 minutes. Some participants will be invited to participate in an evaluation of a specific tool.

Now that I have described the reason for the research study and how it will be conducted, are you still interested in participating?

If Yes: Thank you so much for your willingness to help us. At this point, I have a few additional questions to ask you. The purpose of the questions is to provide AHRQ with an understanding of the demographics of the individuals who are participating in the research study. Answering these questions will take less than 5 minutes. As with all information provided by participants, it will only be provided to AHRQ in summary form.

Also, because we will be conducting the interviews with WebEx, an online collaboration tool, you will need to have access to the Internet during the interview. [CONTINUE TO DEMOGRAPHIC SCREENER UNLESS RESPONDENT INDICATES S/HE HAS NO INTERNET ACCESS, THEN THANK: Thank you for willingness to participate in our study. The interview sessions require access to the Internet. Thank you for speaking with me today and have a great day.]

If No: Thank you for taking the time to talk with me today and have a great day.

Proceed to ask demographic questions

Demographic Section

Q1. Previously, you indicated you considered yourself primarily a [INDICATE ONE: RESEARCHER or IMPLEMENTER]

1. Is that correct? Secure positive answer.

Q2. Which age range best describes you?

1. 18 – 24

2. 25 – 29

3. 30 – 39

4. 40 – 49

5. 50 – 59

6. 60 +

Q3. How many years have you been involved with health IT systems research and/or implementation?

1. 0 – 2 years

2. Over 2 years but less than 5 years

3. Over 5 years but less than 10 years

4. Over 10 years

Q4. Our study interview sessions will be taking place in the MONTH to MONTH timeframe. Do you anticipate you will be available?

1. Yes [GO TO Q5]

2. No – TERMINATE AND THANK

“Based on the study schedule it looks like we can’t include you at this time.”

Q5. ASK ONLY IF NOT OBVIOUS: Are you male or female?

1. Male

2. Female

Q6. Are you Hispanic or Latino/Latina? __ No __ Yes

Q7. What is your race? Please select one or more.

__ American Indian or Alaska Native

__ Asian

__ Native Hawaiian or other Pacific Islander

__ Black or African American

__White

Q8. What is the highest level of education you have completed?

1. 11^th grade or less

2. 12 years of school, no diploma

3. GED or high school graduate (diploma)

4. Some college or technical school

5. College or technical school graduate

6. Post-graduate

Q9. Have you ever visited the AHRQ National Resource Center (NRC) for Health IT Web site, AHRQ’s health IT Web site?

1. Yes

“Have you visited the sections identified on the AHRQ Health IT Web site as “Health IT Tools” or the “Knowledge Library?”

1. No [GO TO CONCLUSION]

2. Yes [Go to Q9]

2. No

“Unless you are asked to visit the AHRQ Health IT Web site as part of your responsibilities as a researcher or implementer, please do not do so prior to being asked to do so by the facilitator as part of the interview process. If you do happen to access the AHRQ Health IT Web site prior to being scheduled for an interview, simply tell the scheduler that is arranging your interview time that you have visited the AHRQ Health IT Web site. In all likelihood you will still be eligible to participate in the study – but it is important for us to know if you have – or have not – visited the AHRQ Health IT Web site prior to the actual interview.

[GO TO CONCLUSION]

3. Not Sure

Q10. When visiting the AHRQ Health IT Web site, have you ever viewed or interacted with a specific tool named the “Health IT Survey Compendium?”

1. Yes

2. No

“Unless you are asked to visit the “Health IT Survey Compendium” as part of your responsibilities as a researcher or implementer, please do not do so unless asked to do so by the facilitator as part of the interview process. If you do happen to access the “Health IT Survey Compendium” prior to being scheduled for an interview, simply tell the scheduler that is arranging your interview time that you have visited the “Health IT Survey Compendium”. In all likelihood you will still be eligible to participate in the study – but it is important for us to know if you have – or have not – visited the “Health IT Survey Compendium” prior to the actual interview.

CONCLUSION

Thank you for your time today.

Your next contact will be with a scheduler from our evaluation team who will arrange a convenient time for you to participate in either an individual or group interview.

Thank you so much for your willingness to help us.

I see you’ve given us [STATE TELEPHONE NUMBER] as the best number at which to reach you? And is there a time of day that is best to contact you?

We look forward to your participation in this evaluation study.

Goodbye.