Form CMS-10360 Screener_Physicians

Screener: Physicians
Target Population:
Group A - Primary Care Providers
Group B - Hospital Internists
Group C - Surgeons (to comprise at least 50% of the total number recruited)
Recruitment Criteria:
Exclude individuals who are current or former employees of the Social Security
Administration or the Department of Health and Human Services or one of its related
agencies (such as the Centers for Medicare & Medicaid Services, the Health Care
Financing Administration, the Agency for Healthcare Research and Quality, the Centers
for Disease Control, the Food and Drug Administration).
Exclude individuals who have participated in a health or health insurance related IDI or
focus group within the past year and/or who have participated in an IDI or focus group
within the past 6 months.

INTRODUCTION:
Hello, my name is _____________ from ______________, a local research firm here in the
____________ area. We are working with L&M Policy Research on a project about health care.
If needed: If recruit asks about L&M Policy Research, please say the following: “L&M
Policy Research is company with headquarters in Washington, D.C that conducts
research on many different health issues.”
I’m calling today about a project that we are doing for the Centers for Medicare & Medicaid
Services, the federal agency that runs Medicare, about adding new patient safety measures as
part of the government’s Hospital Compare website. I’m calling to find out if you would be
available to review these new measures and share your expertise and opinions on how best to
present the information. If you are interested in helping, we will invite you to come for an
interview on __________________. It would take about 60 minutes of your time, and we would
pay you $XX at the end of the interview. May I ask you a few questions to see if you qualify to
participate? If yes, continue to #1. If no, thank and end.
1. Are you a hospital internist?
____ YES → Continue to Question 3
____ NO → Continue to Question 2

2. What type of medicine do you practice?
____ Primary care, internal medicine, or family medicine → Continue to Question 3
____ Surgery→ Continue to Question 3
____ Other → Thank and end call

3. Do you treat mostly adult patients (at least 50% of patients are 18 or older)?
____ YES → Continue
____ NO → Thank and end call

4. Do you currently serve on a hospital QI (quality improvement) committee?
____ YES → Thank and end call
____ NO → Continue
5. Are you currently or have you ever been employed by the Social Security Administration
or the Department of Health and Human Services or one of its related agencies, such as
the Centers for Medicare & Medicaid Services, the Health Care Financing
Administration, the Agency for Healthcare Research and Quality, the Centers for Disease
Control, or the Food and Drug Administration?
____ YES → Thank and end call
____ NO → Continue

6. Have you participated in a health or health insurance related interview, focus group, or
other group discussion in the past year?
____ YES → Thank and end call
____ NO → Continue
____ NOT SURE → Thank and end call

7. Have you participated in any other interview, focus group, or group discussion in the
past 6 months?
____ YES → Thank and end call

____ NO → Continue
____ NOT SURE → Thank and end call
CONTINUE TO INVITATION:
Thank you for answering all of my questions. We would like to invite you to participate in the
study that will take place on [XX]_ at _____________________________ located in
___________________. The interview will last about 60 minutes. As a thank you for your
participation, you will be paid $___.

Are you willing to participate?

Yes____(CONTINUE)

No____(THANK/END)

[Schedule date and time]

Now, let me just verify the spelling of your name and your address, so we can send you a
confirmation letter with directions. (RECORD RESPONDENT’S INFORMATION)
Name:_______________________________Telephone:________________________
Email:_______________________________________
Address:_______________________________________________________________
City, State:____________________________________________Zip:__________________

[IF EMAIL PROVIDED:] Would you rather receive a reminder by email or regular mail?
Email
Regular mail
And if you use reading glasses, please remember to bring them with you.
If you have any questions or find that you can’t attend, please call us right away at
___________________ so that we can find a replacement. Thank you for your time and for
agreeing to help.