Form 1 HIV_Practice_Survey

OMB No.: 0990-XXXX
Expires: XX-XX-20XX

HIV Workforce Survey
Practice Questionnaire

October 21, 2011

Space for survey label here

HIV/AIDS Bureau
Health Resources and Services Administration
United States Department of Health and Human Services
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control number. The valid OMB control number for this information collection is 0990-xxxx. The time required to complete this information collection is estimated to
average 20 minutes per response for the paper survey, including the time to review instructions, search existing data resources, gather the data needed, and complete and
review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S.
Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance
Officer.

INSTRUCTIONS
PLEASE READ

Please complete the survey using this paper questionnaire and return it to Mathematica in the prepaid envelop provided in the survey packet. The survey should take less than 30 minutes to
complete.
All survey questions are about the medical practice located at the address on the questionnaire
cover. For brevity, we refer to this place as “this practice.” It may be public or private, part of a
larger hospital or health care system or an independent and freestanding clinic or practice, a
community health center or public health department clinic, or a solo or group physician practice.
The survey is voluntary. Your answers are confidential, except as prescribed by law. Findings will
be reported in aggregate; no response will be attributable to you or your clinic or practice. The
survey is not related to funding or to other state or federal reporting requirements. Your decision to
complete the survey will have no effect on any funding you or your practice receive for the care and
treatment of patients with HIV or AIDS now or in the future.
The questionnaire has the following sections:
Page
A.

Practice Staffing ................................................................................................................................................. 1

B.

Recruitment and Retention ................................................................................................................................ 3

C.

Practice Capacity ............................................................................................................................................... 8

D.

Perceptions of Workforce Capacity .................................................................................................................. 12

E.

Patient Characteristics ..................................................................................................................................... 14

F.

Contact Information .......................................................................................................................................... 19

General Instructions
• It is fine to reach out to others who work at your practice to help you answer any of the questions.
• In answering the questions requiring numeric responses, it is fine to give your best estimate.
• Italicized notes offer guidance to answering certain questions.
• If there is a “Go To” instruction, go to the question indicated.
• If there is no “Go To” instruction, proceed to the next question.
Thank you for completing this important survey. If you have questions, please contact the HIV
workforce survey helpline at 1-800 xxxxxxxxxx or by email at [email protected].

ii

A. PRACTICE STAFFING
For this section, please consider 1 full-time equivalent (FTE) as a staff member working 40 hours per
week in this practice. For example, if you have one physician providing direct patient care 40 hours per
week and another physician providing direct patient care 20 hours per week, you should report them as
1.5 FTEs in direct patient care. Please include as direct patient care hours spent in both clinical and nonclinical care, such as in patient exam, chart review, clinical documentation, ordering and reviewing lab
tests, case consultations, case management, counseling patients and their families, making referrals, and
telephone consultations with other physicians. Please do NOT include time spent unrelated to patient
care, such as practice management, administrative responsibilities, and professional training.
1.

During the past 12 months, which of the following types of clinicians did this practice use to
provide care to patients with HIV or AIDS? (Check all that apply.)

□
2□
3□
4□
1

2.

Primary care physicians (excluding infectious disease specialists)
Infectious disease specialists
Nurse practitioners
Physician assistants

During the past 12 months, how many of the following types of clinician FTEs in this practice
provided direct medical care to all patients? (If this practice did not use a given type of clinician in
the past 12 months, please record as “Did Not Use.”)
Number of FTEs Providing Care
to ALL Patients

Clinician Category

Did Not
Use

a. Primary care physicians ................................................

|

||

|.|

| FTEs

-1

b. Infectious disease specialists........................................

|

||

|.|

| FTEs

-1

c. Nurse practitioners ........................................................

|

||

|.|

| FTEs

-1

d. Physician assistants ......................................................

|

||

|.|

| FTEs

-1

3.

□
□
□
□

During the past 12 months, how many of the following types of clinician FTEs in this practice
provided direct medical care to patients with HIV or AIDS. (The number of FTEs reported in Q3
should not be greater than the number of FTEs reported in Q2. If all of the clinicians in this practice
treat only patients with HIV or AIDS, the number of FTEs in Q2 and Q3 should be the same. If this
practice did not use a given type of clinician in the past 12 months, please record as “Did Not
Use.”)
Number of FTEs Providing Care
to Patients with HIV or AIDS

Clinician Category

Did Not
Use

a. Primary care physicians ................................................

|

||

|.|

| FTEs

-1

b. Infectious disease specialists........................................

|

||

|.|

| FTEs

-1

c. Nurse practitioners ........................................................

|

||

|.|

| FTEs

-1

d. Physician assistants ......................................................

|

||

|.|

| FTEs

-1

1

□
□
□
□

4.

During the past 12 months, on average how many visits per week was the total number of FTE
HIV clinicians reported in Q3 expected to provide to patients with HIV or AIDS in this practice? (For
example, if this practice used 0.5 FTE infectious disease specialists and 1.5 nurse practitioners,
report the total number of visits per week the 0.5 FTE infection disease specialist was expected to
provide to patients with HIV or AIDS and the total number of visits per week the 1.5 FTE nurse
practitioners were expected to provide to patients with HIV or AIDS. If this practice did not use a
given type of clinician in the past 12 months, please record as “Did Not Use.”)
Average Number of Visits Per
Week for Patients with HIV or
AIDS Seen Per Full-Time HIV
Clinician

Clinician Category

Did Not
Use

a. Primary care physicians ................................................

|

|

|

| VISITS

-1

b. Infectious disease specialists........................................

|

|

|

| VISITS

-1

c. Nurse practitioners ........................................................

|

|

|

| VISITS

-1

d. Physician assistants ......................................................

|

|

|

| VISITS

-1

5.

□
□
□

In this practice, do primary care clinicians independently manage their own panel of patients?
(Independent management of patient panels means the clinician is responsible for managing care
for a designated group of patients and typically serves as the primary point of medical contact for
those patients. Practices that do not use a panel management strategy typically assign patients to
whichever clinician is available at the time of the appointment.)

□
0□
d□
1

5a.

□

Yes, we use a panel management strategy
No, we typically assign patients to whichever clinician is available
GO TO Q6

Don’t know

During the past 12 months, on average how many patients with HIV or AIDS was the total
number of FTE HIV clinicians reported in Q3 expected to manage at this practice? (For example, if
this practice used 0.5 FTE infectious disease specialists and 1.5 nurse practitioners, report the total
number of patients with HIV or AIDS the 0.5 FTE infection disease specialist was expected to
manage and the total number of patients with HIV or AIDS the 1.5 FTE nurse practitioners were
expected to manage. For clinician types that do not manage patient panels at this practice, please
record as zero. If this practice did not use a given type of clinician in the past 12 months, please
record as “Did Not Use.”)
Average Number of Patients
with HIV or AIDS Managed
Per Full Time HIV Clinician

Clinician Category

Did Not
Use

a. Primary care physicians ................................................

|

|

|

| PATIENTS

-1

b. Infectious disease specialists........................................

|

|

|

| PATIENTS

-1

c. Nurse practitioners ........................................................

|

|

|

| PATIENTS

-1

d. Physician assistants ......................................................

|

|

|

| PATIENTS

-1

2

□
□
□
□

B. RECRUITMENT AND RETENTION

6.

During the past 12 months, how many vacancies for HIV clinicians (by FTE) did this practice fill?
(Include only positions for clinicians who provide care to patients with HIV or AIDS. If there were no
vacancies to report for a given type of clinician used, please record as zero.)
Number of Vacancies for HIV Clinicians
Filled in Past 12 Months (in FTEs)

Clinician Category
a. Primary care physicians ..............................................

|

||

|.|

| FTEs

b. Infectious disease specialists ......................................

|

||

|.|

| FTEs

c. Nurse practitioners ......................................................

|

||

|.|

| FTEs

d. Physician assistants ....................................................

|

||

|.|

| FTEs

6a.

What was the average length of time (in months) it took to fill the HIV clinician vacancies? (Include
time periods only for clinicians who provide care to patients with HIV or AIDS. If there were no
vacancies to report for a given type of clinician used, please record as zero.)
Average Length of Time Position for HIV
Clinician was Vacant (in Months)

Clinician Category

7.

a. Primary care physicians ..............................................

|

||

|.|

| Months

b. Infectious disease specialists ......................................

|

||

|.|

| Months

c. Nurse practitioners ......................................................

|

||

|.|

| Months

d. Physician assistants ....................................................

|

||

|.|

| Months

How many funded but currently vacant positions for HIV clinicians (by FTE) are there in this
practice? (Include vacancies only for clinicians who provide care to patients with HIV or AIDS and
only those positions with existing funding support. If there are no current vacancies to report for a
given type of clinician used, please record as zero.)
Currently Funded Vacancies for HIV
Clinicians (in FTEs)

Clinician Category
a. Primary care physicians ..............................................

|

||

|.|

| FTEs

b. Infectious disease specialists ......................................

|

||

|.|

| FTEs

c. Nurse practitioners ......................................................

|

||

|.|

| FTEs

d. Physician assistants ....................................................

|

||

|.|

| FTEs

3

7a.

What is the average length of time (in months) these currently open positions have been vacant?
(Include time periods only for clinicians who provide care to patients with HIV or AIDS, and only
those positions with existing funding support. If there are no vacancies to report for a given type of
clinician used, please record as zero.)
Average Length of Time Position for
HIV Clinician Has Been Vacant
(in Months)

Clinician Category
a. Primary care physicians ..................................................

|

||

|.|

| Months

b. Infectious disease specialists ..........................................

|

||

|.|

| Months

c. Nurse practitioners ..........................................................

|

||

|.|

| Months

d. Physician assistants ........................................................

|

||

|.|

| Months

8.

During the past 12 months, in your practice how difficult was it to recruit the following types of
clinicians who provide care to patients with HIV or AIDS? (Mark only one in each row. If this
practice did not use a given type of clinician, please record as “Did Not Recruit.”)

Clinician Category

Very
Difficult

a. Primary care physicians .......................

1

b. Infectious disease specialists ...............

1

c.

Nurse practitioners ...............................

1

d. Physician assistants .............................

1

8a.

□

Somewhat
Difficult
2

□

2

□

2

□

2

Somewhat
Easy

□

3

□

3

□

3

□

3

□

Very
Easy
4

□

4

□

4

□

4

Did Not
Recruit

□

-1

□

-1

□

-1

□

-1

□
□
□
□

How big a challenge was each of the following factors to recruiting physicians who provide care to
patients with HIV or AIDS? (Please indicate if each factor is a big challenge, a small challenge, or
not a challenge at all. Mark only one in each row.)
If physicians were not recruited within the past 12 months, check here and continue to next item: o □
BIG
CHALLENGE

Recruiting Challenges
a. Low pay scale or inadequate reimbursement for
treating patients with HIV or AIDS

1

b. Not enough clinicians with HIV experience and/or
training

1

c.

Not enough clinicians willing to work with patients
with HIV or AIDS

1

d. Not enough qualified clinicians willing to work in
rural areas

1

e. Not enough qualified clinicians willing to work in
low-income urban communities

1

4

□
□
□
□
□

SMALL
CHALLENGE
2

2

2

2

2

□
□
□
□
□

NOT A
CHALLENGE
3

3

3

3

3

□
□
□
□
□

f.

Insufficient funds to hire new clinicians

1

g. Not enough J1 visas or other immigration
problems

1

h. Clinicians consider HIV workload to be too heavy
or too burdensome

1

i.

1

8b.

Other (Please specify)_____________________

□

2

□

2

□

2

□

2

□

3

□

3

□

3

□

3

□
□
□
□

How big a challenge was each of the following factors to recruiting nurse practitioners and
physician assistants who provide care to patients with HIV or AIDS? (Please indicate if each
factor is a big challenge, a small challenge, or not a challenge at all. Mark only one in each row.)
If nurse practitioners and physician assistants were not recruited within the past 12 months, check
here and continue to next item: o □

BIG
CHALLENGE

Recruiting Challenges
a. Low pay scale or inadequate reimbursement for
treating patients with HIV or AIDS

1

b. Not enough clinicians with HIV experience and/or
training

1

c.

Not enough clinicians willing to work with patients
with HIV or AIDS

1

d. Not enough qualified clinicians willing to work in
rural areas

1

e. Not enough qualified clinicians willing to work in
low-income urban communities

1

f.

1

Insufficient funds to hire new clinicians

g. Not enough J1 visas or other immigration
problems

1

h. Clinicians consider HIV workload to be too heavy
or too burdensome

1

i.

1

9.

Other (Please specify)_____________________

SMALL
CHALLENGE

□

2

□

2

□

2

□

2

□

2

□

2

□

2

□

2

□

2

□

NOT A
CHALLENGE
3

□

3

□

3

□

3

□

3

□

3

□

3

□

3

□

3

□
□
□
□
□
□
□
□
□

During the past 12 months, in this practice, how difficult was it to retain each of the following
types of clinicians who provide care to patients with HIV or AIDS? (Mark only one in each row. If
this practice did not use a given type of clinician, please record as “Did Not Use.”)

Clinician Category

Very
Difficult

a. Primary care physicians .......................

1

b. Infectious disease specialists ...............

1

c.

1

Nurse practitioners ...............................

□

Somewhat
Difficult
2

□

2

□

2

5

□
□
□

Somewhat
Easy
3

3

3

□
□
□

Very
Easy
4

4

4

□
□
□

Did Not
Use
-1

-1

-1

□
□
□

d. Physician assistants .............................

9a.

1

□

2

□

3

□

4

□

-1

□

How big a challenge was each of the following factors to retaining physicians who provide care to
patients with HIV or AIDS? (Please indicate if each factor is a big challenge, a small challenge, or
not a challenge at all. Mark only one in each row.)
If physicians were not used at this practice, check here and continue to next item: o □
BIG
CHALLENGE

Retention Challenges
a. Inadequate funds to cover staff salaries

1

b. Clinicians consider pay scale or reimbursement
for treating patients with HIV or AIDS too low

1

c.

Clinicians consider indirect demands on their time
too burdensome (for example, paperwork)

1

d. Clinicians consider HIV workload too heavy (for
example, volume of patients)

1

e. Clinicians choosing to retire from health
profession

1

f.

Clinicians choosing to shift into non-HIV-related
patient care field

1

g. Clinicians choosing to relocate to other area or
practice setting

1

h. Issues related to J1 visas or other immigration
issues

1

i.

1

9b.

Other (Please specify)_____________________

□
□
□
□
□
□
□
□
□

SMALL
CHALLENGE
2

2

2

2

2

2

2

2

2

□
□
□
□
□
□
□
□
□

NOT A
CHALLENGE
3

3

3

3

3

3

3

3

3

□
□
□
□
□
□
□
□
□

How big a challenge was each of the following factors to retaining nurse practitioners and/or
physician assistants who provide care to patients with HIV or AIDS? (Please indicate if each
factor is a big challenge, a small challenge, or not a challenge at all. Mark only one in each row.)
If nurse practitioners and physician assistants were not used at this practice, check here and

continue to next item: o □

BIG
CHALLENGE

Retention Challenges
a. Inadequate funds to cover staff salaries

1

b. Clinicians consider pay scale or reimbursement
for treating patients with HIV or AIDS too low

1

c.

Clinicians consider indirect demands on their time
too burdensome (for example, paperwork)

d. Clinicians consider HIV workload too heavy (for
example, volume of patients)

6

1

1

□
□
□
□

SMALL
CHALLENGE
2

2

2

2

□
□
□
□

NOT A
CHALLENGE
3

3

3

3

□
□
□
□

e. Clinicians choosing to retire from health
profession
f.

1

Clinicians choosing to shift into non-HIV-related
patient care field

1

g. Clinicians choosing to relocate to other area or
practice setting

1

h. Issues related to J1 visas or other immigration
issues

1

i.

1

10.

Other (Please specify)_____________________

□

2

□

2

□

2

□

2

□

2

□

3

□

3

□

3

□

3

□

3

□
□
□
□
□

During the past 12 months, in this practice, what was the average annual salary for the following
full-time positions for clinicians providing care to patients with HIV or AIDS? (If this practice did not
use a given type of clinician, please record as zero.)
Average Annual Salary for Clinicians
Treating Patients with HIV or AIDS

Clinician Category
a. Primary care physicians

$|

|

|

|,|

|

|___|

b. Infectious disease specialists

$|

|

|

|,|

|

|___|

c.

$|

|

|

|,|

|

|___|

$|

|

|

|,|

|

|___|

Nurse practitioners

d. Physician assistants

7

C. PRACTICE CAPACITY

11.

In a typical week, approximately how many patient visits for medical care does this practice
currently conduct? (Please include only visits for medical care. In row “a,” count all patient visits
and, in row “b,” only visits for patients with HIV or AIDS. The number of visits reported in row “b”
must not be less than the number of visits reported in row “a.” If you only treat patients with HIV or
AIDS, the number of visits reported in both rows will be the same.)
Total Medical Visits in a Typical Week…

12.

a.

All patients

|___|___|___|

b.

Patients with HIV or AIDS

|___|___|___|

Assuming no change in your current resource levels, such as funding and staffing, how many
medical visits for patients with HIV or AIDS in addition to those you are currently providing
could this practice absorb without compromising the quality of care provided?
|

13.

Visits

|

|

| NUMBER OF ADDITIONAL VISITS

Currently, for each of the following appointment types, what is the average waiting time for a
nonemergency medical visit with a primary care clinician in this practice? (Mark only one in each
row.)
Average Waiting Time for a Medical Visit

Appointment Type

14.

Less
Than 1
Week

a. Initial medical appointment for
patients newly diagnosed with HIV
or AIDS

1

b. Follow-up medical appointment for
patients with HIV or AIDS who are
in ongoing care

1

□
□

2

2

□
□

2
Weeks

3

3

□
□

3
Weeks

4

4

4
Weeks

□
□

5

5

□
□

More
Than 4
Weeks

6

6

□
□

Currently, for each of the following appointment types, what is the average length of a typical
medical visit with a primary care clinician in this practice?
Appointment Type

15.

1
Week

Minutes per Typical Visit

a. Initial medical appointment for patients
newly diagnosed with HIV or AIDS

|___|___|___|

b. Follow-up medical appointment for patients
with HIV or AIDS who are in ongoing care

|___|___|___|

Currently, is this practice accepting new Medicaid patients with HIV or AIDS for medical care? (For
patients with multiple sources of coverage, please consider their primary payer source only. Mark
only one.)

8

1

2

0

□

Yes, with no limitations on care provision

□

Yes, with some limitations on care provision

□

No, completely closed to all new Medicaid patients with HIV

GO TO Q16

15a. How important were the following factors in the decision to limit or close this practice to new
Medicaid patients with HIV or AIDS? (Mark only one in each row.)

Very
Important

Factors

16.

a. Administrative requirements

1

b. Complex needs of HIV patients

1

c.

1

Overall HIV patient load

d. Inadequate reimbursement or
funding for HIV care

1

e. Not enough providers

1

□
□
□
□
□

Moderately
Important
2

2

2

2

2

□
□
□
□
□

Not Very
Important
3

3

3

3

3

□
□
□
□
□

Not
Important
At All
4

4

4

4

4

□
□
□
□
□

Currently, is this practice accepting new Medicare patients with HIV or AIDS for medical care? (For
patients with multiple sources of coverage, please consider their primary payer source only. Mark
only one.)
1

2

0

□

Yes, no limitations

□

Yes, some limitations

□

No, completely closed to all new Medicare patients with HIV

GO TO Q.17

16a. How important were the following factors in the decision to limit or close this practice to new
Medicare patients with HIV or AIDS? (Mark only one in each row.)

Factors

Very
Important

a. Administrative requirements

1

b. Complex needs of HIV patients

1

c.

1

Overall HIV patient load

d. Inadequate reimbursement or
funding for HIV care

1

e. Not enough providers

1

9

□
□
□
□
□

Somewhat
Important
2

2

2

2

2

□
□
□
□
□

Not Very
Important
3

3

3

3

3

□
□
□
□
□

Not
Important
At All
4

4

4

4

4

□
□
□
□
□

17.

Currently, is this practice accepting new privately insured patients with HIV or AIDS? for medical
care? (For patients with multiple sources of coverage, please consider their primary payer source
only. Mark only one.)
1

2

0

□

Yes, no limitations

□

Yes, some limitations

□

No, completely closed to all new commercially insured patients with HIV

GO TO Q.18

17a. How important were the following factors in the decision to limit or close this practice to new
privately insured patients with HIV or AIDS? (For patients with multiple sources of coverage,
please consider their primary payer source only. Mark only one in each row.)

Very
Important

Factors

18.

a. Administrative requirements

1

b. Complex needs of HIV patients

1

c.

1

Overall HIV patient load

d. Inadequate reimbursement or
funding for HIV care

1

e. Not enough providers

1

□
□
□
□
□

Somewhat
Important
2

2

2

2

2

□
□
□
□
□

Not Very
Important
3

3

3

3

3

□
□
□
□
□

Not
Important
At All
4

4

4

4

4

□
□
□
□
□

Currently, is this practice accepting new uninsured patients with HIV or AIDS? (Mark only one.)
1

2

0

□

Yes, no limitations

□

Yes, some limitations

□

No, completely closed to all new commercially insured patients with HIV

GO TO Q.19

18a. How important were the following factors in the decision to limit or close this practice to new
uninsured patients with HIV or AIDS? (Mark only one in each row.)

Factors

Very
Important

a. Administrative requirements

1

b. Complex needs of HIV patients

1

c.

1

Overall HIV patient load

d. Inadequate reimbursement or
funding for HIV care

1

e. Not enough providers

1

10

□
□
□
□
□

Somewhat
Important
2

2

2

2

2

□
□
□
□
□

Not Very
Important
3

3

3

3

3

□
□
□
□
□

Not
Important
At All
4

4

4

4

4

□
□
□
□
□

D. PERCEPTION OF WORKFORCE CAPACITY
19.

In your opinion, is the current supply of clinicians providing direct medical care to patients with HIV
or AIDS in your community…? (Mark only one.)

□
2□
3□
1

20.

Greater than demand (clinician surplus)
Balanced with demand
Less than demand (clinician shortage)

Please rate the following statement on a scale of 1 – 4 for each type of clinician. Use a scale of 1 to
4, where 1 means you strongly disagree with it and 4 means you strongly agree with it. (Mark
only one for each type of clinician.)
I am concerned about a shortage in the number of the following types of clinicians
providing direct medical care to patients with HIV or AIDS in my community over the next 5
years.

I am concerned about a shortage in the
number of…

Strongly
Disagree

Disagree

Agree

Strongly
Agree

a. Primary care physicians

1

□

2

□

3

□

4

□

b. Infectious disease specialists

1

□

2

□

3

□

4

□

c.

1

□

2

□

3

□

4

□

1

□

2

□

3

□

4

□

Nurse practitioners

d. Physician assistants
21.

Please rate the effectiveness of the following strategies for meeting an increase in the demand for
medical services among patients with HIV or AIDS without compromising the quality of care
provided in your community. Use a scale of 1 to 4, where 1 means it is not effective and 4 means
it is highly effective.

Strategies

Not
Effective

Slightly
Effective

Moderately
Effective

Highly
Effective

a. Train more students and primary care clinicians
to go into care for patients with HIV or AIDS

1

□

2

□

3

□

4

□

b. Expand the government loan forgiveness
program for clinicians providing care to patients
with HIV or AIDS

1

□

2

□

3

□

4

□

1

□

2

□

3

□

4

□

d. Increase the use of non-HIV primary care
physicians for the treatment of patients with HIV
or AIDS

1

□

2

□

3

□

4

□

e. Increase the use of health information
technology, including sharing medical records,
ordering prescriptions, and ordering and
receiving lab tests

1

□

2

□

3

□

4

□

c.

Increase the use of nurse practitioners and
physician assistants in managing care for
patients with HIV or AIDS

11

f.

Increase the use of advanced primary care
models to improve disease management and
care coordination

1

□

2

□

3

□

4

□

g. Create incentives for clinicians to delay
retirement or remain in medical care for patients
with HIV or AIDS

1

□

2

□

3

□

4

□

h. Other (Please specify)
____________________________

1

□

2

□

3

□

4

□

12

E. PATIENT CHARACTERISTICS
Questions in this section refer to this practice’s most recent 12-month reporting period. If you submitted a
2010 RDR to HRSA, please feel free to use the information presented in that report. Please count each
patient only once, regardless of how many times the individual was seen during the reporting period. Your
best estimate of patient counts is fine.
Please indicate the 12-month period you are reporting:
Start Month/Year ____________________________ End Month/Year____________________________

22.

During this practice’s most recent 12-month reporting period, approximately how many
patients in each of the following HIV status categories did your practice serve? If this practice did
not provide care to a given type of patient, please record as zero.)
Number of Patients Served
in 12-Month Reporting Period

Diagnostic Categories
a. Without HIV or AIDS diagnosis

|

|

|

|

| PATIENTS

b. With HIV diagnosis, but not AIDS diagnosis

|

|

|

|

| PATIENTS

c.

|

|

|

|

| PATIENTS

|

|

|

|

| PATIENTS

With AIDS diagnosis

d. Total Patients

23.

Of the patients with HIV or AIDS served at this practice during the most recent 12-month
reporting period, approximately what percentage was in each of the following care categories?
(Please feel free to report percentages or numbers, whichever is easier. You do not need to report
both. The total percentage must add up to 100 percent. If this practice did not provide care to a
given type of patient, please record as zero.)
Percent of Patients
with HIV or AIDS

Care Category

Number of Patients
with HIV or AIDS

a. Diagnosed with HIV or AIDS within the
past 12 months

|

|

|

|%

|

|

|

| PATIENTS

b. Not newly diagnosed, but new to your
practice within the past 12 months

|

|

|

|%

|

|

|

| PATIENTS

|

|

|

|%

|

|

|

| PATIENTS

c.

Established in care in your practice for the
past 12 months

TOTAL

100%

13

24.

Of the patients with HIV or AIDS served at this practice during the most recent 12-month
reporting period, approximately what percentage also had each of the following comorbidities?
(Please feel free to report percentages or numbers, whichever is easier. You do not need to report
both. Percentages do not need to add up to 100 percent. If this practice did not provide care to a
given type of patient, please record as zero.)
Percent of Patients
with HIV or AIDS

Comorbidities
a. Serious mental illness (including affective
disorders such as depression and anxiety)

|

|

|

|%

|

|

|

| PATIENTS

b. A substance abuse disorder

|

|

|

|%

|

|

|

| PATIENTS

c.

|

|

|

|%

|

|

|

| PATIENTS

|

|

|

|%

|

|

|

| PATIENTS

Hepatitis B or C

d. Other significant comorbidities

25.

Of the patients with HIV or AIDS served at this practice during the most recent 12-month
reporting period, approximately what percentage was in each of the following antiretroviral
therapy categories? (Please feel free to report percentages or numbers, whichever is easier. You
do not need to report both. The total percentage must add up to 100 percent. If this practice did not
provide care to a given type of patient, please record as zero.)
Percent of Patients
with HIV or AIDS

Antiretroviral Therapy

Number of Patients
with HIV or AIDS

a. None

|

|

|

|%

|

|

|

| PATIENTS

b. HAART

|

|

|

|%

|

|

|

| PATIENTS

c.

|

|

|

|%

|

|

|

| PATIENTS

|

|

|

|%

|

|

|

| PATIENTS

Other (mono or dual therapy)

d. Unknown
TOTAL

26.

Number of Patients
with HIV or AIDS

100%

Of the patients with HIV or AIDS served at this practice during the most recent 12-month
reporting period, approximately what percentage was in each of following age categories?
(Please feel free to report percentages or numbers, whichever is easier. You do not need to report
both. The total percentage must add up to 100 percent. If this practice did not provide care to a
given type of patient, please record as zero.)
Percent of Patients
with HIV or AIDS

Age

Number of Patients
with HIV or AIDS

a. Under 2 years

|

|

|

|%

|

|

|

| PATIENTS

b. 2-12 years

|

|

|

|%

|

|

|

| PATIENTS

c

|

|

|

|%

|

|

|

| PATIENTS

13-24 years

14

d. 25-44 years

|

|

|

|%

|

|

|

| PATIENTS

e. 45-64 years

|

|

|

|%

|

|

|

| PATIENTS

f.

|

|

|

|%

|

|

|

| PATIENTS

|

|

|

|%

|

|

|

| PATIENTS

65 and older

g. Unknown
TOTAL

27.

100%

Of the patients with HIV or AIDS served at this practice during the most recent 12-month
reporting period, approximately what percentage was in each of the following gender categories?
(Please feel free to report percentages or numbers, whichever is easier. You do not need to report
both. The total percentage must add up to 100 percent. If this practice did not provide care to a
given type of patient, please record as zero.)
Percent of Patients
with HIV or AIDS

Gender
a. Male

|

|

|

|%

|

|

|

| PATIENTS

b. Female

|

|

|

|%

|

|

|

| PATIENTS

c.

|

|

|

|%

|

|

|

| PATIENTS

|

|

|

|%

|

|

|

| PATIENTS

Transgendered

d. Unknown
TOTAL

28.

100%

Of the patients with HIV or AIDS served at this practice during the most recent 12-month
reporting period, approximately what percentage (or number) were Hispanic or Latino/a?
|

29.

Number of Patients
with HIV or AIDS

|

|

| PERCENT or |

|

|

| PATIENTS

Of the patients with HIV or AIDS served at this practice during the most recent 12-month
reporting period, approximately what percentage (or number) was in each of the following race
categories? (Please feel free to report percentages or numbers, whichever is easier. You do not
need to report both. The total percentage must add up to 100 percent. If this practice did not
provide care to a given type of patient, please record as zero.)
Percent of Patients
with HIV or AIDS

Race

Number of Patients
with HIV or AIDS

a. American Indian or Alaskan Native

|

|

|

|%

|

|

|

| PATIENTS

b. Asian

|

|

|

|%

|

|

|

| PATIENTS

c.

|

|

|

|%

|

|

|

| PATIENTS

d. Native Hawaiian or Pacific Islander

|

|

|

|%

|

|

|

| PATIENTS

e. White

|

|

|

|%

|

|

|

| PATIENTS

Black or African American

15

f.

More than one race

g. Unknown

|

|

|

|%

|

|

|

| PATIENTS

|

|

|

|%

|

|

|

| PATIENTS

TOTAL

30.

Of the patients with HIV or AIDS served at this practice during the most recent 12-month
reporting period, approximately what percentage (or number) were undocumented immigrants?
(If this practice did not provide care to a given type of patient, please record as zero.)
|

31.

100%

|

|

| PERCENT or |

|

|

| PATIENTS

Of the patients with HIV or AIDS you served, approximately what percentage was in each of the
following health insurance categories? (If a patient has multiple sources of insurance, please
count them only once under their primary payer. Please feel free to report percentages or numbers,
whichever is easier. You do not need to report both. The total percentage must add up to 100
percent. If this practice did not provide care to a given type of patient, please record as zero.)
Percent of Patients
with HIV or AIDS

Health Insurance
a. Privately insured

|

|

|

|%

|

|

|

| PATIENTS

b. Medicaid only

|

|

|

|%

|

|

|

| PATIENTS

c.

|

|

|

|%

|

|

|

| PATIENTS

d. Both Medicaid and Medicare

|

|

|

|%

|

|

|

| PATIENTS

e. Other public insurance (VA or Indian
Health)

|

|

|

|%

|

|

|

| PATIENTS

f.

|

|

|

|%

|

|

|

| PATIENTS

g. Other (Please
specify)____________________

|

|

|

|%

|

|

|

| PATIENTS

h. Unknown

|

|

|

|%

|

|

|

| PATIENTS

Medicare only

Self pay or uninsured

TOTAL

32.

Number of Patients
with HIV or AIDS

100%

During your most recent 12-month reporting period, approximately how many relative value
units (RVUs) did this practice produce? (In row “a,” count RVUs for all patients, in row “b,” count
RVUs only for those patients with HIV or AIDS.)
Relative value units (RVUs) for…

RVUs

a. All patients

|

||

|.|

|

| RVUs

b. Patients with HIV or AIDS

|

||

|.|

|

| RVUs

c.

c□

Don’t use RVUs

d□

d. Don’t know

16

F. CONTACT INFORMATION

In case we need to contact you to clarify any of your answers, please provide the
following information for the person who completed the majority of this survey:

Name:_________________________________________________________________________
Title: __________________________________________________________________________
Address:________________________________________________________________________
Phone Number: (| | | |)-|
Area Code

|

|

|-|

|

|

Email Address:

|

|

_________________________

Thank you for completing the survey!

17