Nurse Screener

Attachment 4: Screening Instrument for Nurses

Asthma Education Study

April 2012

Project Officer: Scott A. Damon, MAIA, CPH, RPCV

Centers for Disease Control and Prevention

National Center for Environmental Health

Division of Environmental Hazards and Health Effects

Air Pollution and Respiratory Health Branch

Form Approved

OMB No. 0920-XXXX¹

Exp. Date xx/xx/2012

Asthma Education Study

• Recruit eight (8) physicians per market

• At least 2 Pediatricians

• At least 2 Family Practitioners

• At least 2 specializing in Internal Medicine

• 30-minute In-depth Interviews (IDIs)

Recruit into times indicated in table

Local Time	Activity	Local Time	Activity
12:00 – 12:30	Physician IDI	3:30 – 4:00	Physician IDI
12:30 – 1:00	Physician IDI	4:00 – 4:30	Physician IDI
1:00 – 1:30	Physician IDI	4:30 – 5:00	Physician IDI
1:30 – 2:00	Physician IDI	5:00 – 6:00	Dinner Break
2:00 – 2:30	Physician IDI	6:00 – 7:00	Nurse Focus Group
2:30 – 3:30	Break	7:15 – 8:15	Nurse Focus Group

Hello, my name is ____________________with _____________ a market research firm. . We are talking today with physicians in the area about a public health issue. We are not selling anything. This data collection is being sponsored by the Centers for Disease Control and Prevention. We have a few brief questions and if you qualify and are interested, we will invite you to take part in an interview that will take place at a later date. To see if you qualify for an interview, I need to ask you a few questions.

1. Is anyone in your immediate family employed in the following industries? (IF YES TO ANY, THANK &TERMINATE)

01 Advertising or public relations

02 Market research

03 News media – works for a newspaper, TV station, radio station, or some other form of news media

04 Federal government

05 Pharmaceutical companies

06 None (CONTINUE)

2. Which, if any, of the following describe your specialty? (READ LIST)

01 Pediatrician

02 Family Practice

03 Internal Medicine

04 General Practice

05 Other (THANK AND TERMINATE)

(DOCUMENT ON GRID)

3. Are you board-certified in your specialty?

01 Yes

02 No (THANK AND TERMINATE)

4. For what percentage of your patients do you act as their primary care physician?

01 50% or more

02 Less than 50% (THANK AND TERMINATE)

5. In a typical year, for how many patients do you provide their initial diagnosis of asthma?

01 Less than 12 (THANK AND TERMINATE)

02 12 or more

6. Is your primary work

01 In a private practice

02 At a hospital or university (THANK AND TERMINATE)

7. What is the business name of your practice?

___________________________________________________________

(NO MORE THAN 1 RESPONDENT FROM A PRACTICE)

(DO NOT RECORD PRACTICE NAME ON GRID)

8. Would you please tell me your race?

01 American Indian or Alaska Native

02 Asian

03 Black or African American

04 Native Hawaiian or Other Pacific Islander

05 White

[DOCUMENT ON GRID; NOT A SCREENING CRITERION]

9. Would you please tell me your ethnicity?

01 Hispanic or Latino

02 Not Hispanic or Latino

[DOCUMENT ON GRID; NOT A SCREENING CRITERION]

10. [GENDER: DOCUMENT ON GRID; NOT A SCREENING CRITERION]

11. [ASSESS AND VERIFY ABILITY TO SPEAK AND UNDERSTAND ENGLISH]

Your interview will be held on ___________________ at ______________. and will last for approximately 30 minutes. Because we know your time is valuable, at the end of the discussion we will pay you $50 for participating.

Are you willing to attend?

1. Yes

2. No (THANK & TERMINATE)

Name_________________________________________________________________

Address________________________________________________________________

City/State/Zip___________________________________________________________

Day Number_________________________Night Number________________________

1 Public reporting burden of this collection of information is estimated to be 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.

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