Hospital Induction Form

ATTACHMENT I:
NHAMCS Hospital Induction Form

OMB No. 0920-0278; Exp. Date: ________ 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 individual 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). Notice – Public reporting burden for this collection of information is estimated to average 90 minutes per response, including 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 current valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing burden to: CDC/ATSDR Information Collection Review Office, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0278).
	INTRO_APPT
	Text:			Hello, This is ... from the U.S. Census Bureau.  I'm (calling/visiting) to let you know that this hospital will be included in our study. I would like to arrange to meet with you so that I can better present the details of the study. Is there a convenient time within the next week or so that I could meet with you or your representative?        Enter 999 to start the induction interview
	NAMECHEK
	Text:			Let me verify that I have the correct name and address for your hospital. Is the correct name (facility name)?
	1.			Yes
	2.			No
	HSP_NAME
	Text:			What is your hospital's name?        Enter 1 to update the hospitals name
	1.			Enter 1 to update information
	2.			Continue
	ADDCHEK
	Text:			Is your hospital located at (Facility Address)
	1.			Yes
	2.			No
	HSP_ADDRESS
	Text:			What is the correct address?         Enter 1 to update the hospitals address
	MAILADD
	Text:			Is this also the mailing address?       (Facility Address)
	1.			Yes
	2.			No
	MHSP_STRET
	Text:			What is the correct mailing address?           Enter the number and street or press enter if same
	INTRO_AB
	Text:			(Although you have not received the letter,) I'd like to briefly explain the study to you at this time and answer any questions about it. The National Center for Health Statistics of the Centers for Disease Control and Prevention is (conducting an/continue its) annual study of hospital-based ambulatory care.  (Intro for the survey) Before discussing the details, I would like to verify our basic information about (facility name) to be sure we have correctly included this hospital in the study.  First, concerning licensing:
	LICHOSP
	Text:			Is this facility a licensed hospital?
	1.			Yes
	2.			No
	OWN101
	Text:			Is this hospital nonprofit, government, or proprietary?
	1.			Nonprofit (includes church-related, nonprofit corporation, other nonprofit ownership)
	2.			State or local government (includes state, county, city, city-county, hospital district or authority)
	3.			Proprietary (includes individually or privately owned, partnership or corporation)
	OWNHCC
	Text:			Is this hospital owned, operated, or managed by a health care corporation that owns multiple health care facilities (e.g., HCA or Health South)?
	1.			Yes
	2.			No
	3.			Unknown
	TEACHOSP
	Universe:			LICHOSP = 1
	Text:			Is this a teaching hospital?
	1.			Yes
	2.			No
	MERGER
	Text:			Did this hospital either merge or separate from any OTHER hospital in the past 2 years?
	1.			Merged or separated
	2.			No
	3.			Unknown
	MERSEP
	Text:			Was this a merger or a separation?
	MERGMEDR
	Text:			Does YOUR hospital have its own medical records department that is separate from that of the OTHER hospital?
	1.			Yes
	2.			No
	3.			Unknown
	OTHNAME
	Text:			What is the name and address of this OTHER hospital?
	ESA24
	Text:			Does this hospital provide emergency services that are staffed 24 HOURS each day either here at this hospital or elsewhere?
	1.			Yes
	2.			No
	ESANOT24
	Text:			Does this hospital operate any emergency service areas that are not staffed 24 HOURS each day?
	1.			Yes
	2.			No
	TRAUMA
	Text:			What is the trauma level rating of this hospital?
	1.			Level I
	2.			Level II
	3.			Level III
	4.			Level IV
	5.			Level V
	6.			Other/unknown
	7.			None
	OOOPD
	Text:			Does this hospital operate an organized outpatient department either at this hospital or elsewhere?
	1.			Yes
	2.			No
	PHYSSERV
	Text:			Does this OPD include physician services?
	1.			Yes
	2.			No
	AMBSURG
	Text:			Does this hospital have locations that perform ambulatory surgery? Ambulatory surgery locations include a general or main operating room, dedicated ambulatory surgery room, satellite operating room, cystoscopy room, endoscopy room, cardiac catheterization lab, laser procedures room, or a pain block room.
	1.			Yes
	2.			No
	3.			Unknown
	ELIGREQ
	Text:			** Not displayed **
	STUDY_DESC
	Text:			Thank you.          Explain the following ONLY if this is a new hospital.  Provide the administrator or other hospital representative with a brief description of the study.  Cover the following points Now I would like to provide you with further information on the study.         (1)    NHAMCS is the only source of national data on health care provided in hospital emergency and outpatient departments and ambulatory surgery centers.         (2)    NHAMCS is endorsed by the:                         American College of Emergency Physicians                        Emergency Nurses Association                        Society for Academic Emergency Medicine                        American College of Osteopathic Emergency Physicians                        Federation of American Hospitals                                Ambulatory Surgery Center Association                        American College of Surgeons                        American Health Information Management Association                        American Academy of Ophthalmology                        Society for Ambulatory Anesthesia          (3)  Nationwide sample of about 600 hospitals and 246 freestanding ambulatory surgery centers.          (4)  Four-week data collection period          (5) Brief form completed for a sample of patient visits. As one of the hospitals that has been selected for the study, your contribution will be of great value in producing reliable, national data on ambulatory care.
	INDUCTION_APPT
	Text:			I would like to arrange to meet with you so that I can better present the details of the study. Is there a convenient time within the next week or so that I could meet with you or your representative?               Record day, date and time of appointment             Enter 999 if the respondent wants to continue with the induction now
	SCREENER_THK
	Text:			Thank you for your cooperation.  I am looking forward to our meeting.
	THANK_MERGSEP
	Text:			Since your hospital has merged or separated within the last 2 years, I need to get further instructions from the Centers for Disease Control and Prevention (CDC) on how to proceed.  I will call you back within a week and let you know which parts of your hospital will be in the survey.  Thank you for your cooperation.
	CALLRO_MERGSEP
	Text:			Call your RO and inform them of the situation.      Await resolution from the RO before continuing with this case.
	THANK_B1
	Text:			Thank you, but it seems that our information is incorrect. Since (facility name) is not a licensed hospital, it should not have been chosen for our study. Thank you very much for your cooperation.
	THANK_B2
	Text:			Thank you, but it seems that our information is incorrect. Since (facility name) does not have 24-hour emergency services, outpatient clinics, or ambulatory surgery centers, it should not have been chosen for our study.  Thank you very much for your cooperation.
	REVIEW
	Text:			? [F1] I would like to begin with a brief review of the background for this study.            Provide the administrator or other hospital representative with a brief introduction to the study and a general overview of procedures.  Press F1 for points to be covered
	SURGDAY
	Text:			Now I would like to ask you a few more questions about your hospital. How many days in a week are inpatient elective surgeries scheduled?           Enter CTRL-D if unknown
	BEDCZAR
	Text:			Does your hospital have a bed coordinator, sometimes referred to as a bed czar?
	1.			Yes
	2.			No
	3.			Unknown
	BEDDATA
	Text:			How often are hospital bed census data available?
	1.			Instantaneously
	2.			Every 4 hours
	3.			Every 8 hours
	4.			Every 12 hours
	5.			Every 24 hours
	6.			Other
	7.			Unknown
	HLIST
	Text:			Does your hospital have hospitalists on staff? A hospitalist is a physician whose primary professional focus is the general care of hospitalized patients.  He/she may oversee ED patients being admitted to the hospital.
	1.			Yes
	2.			No
	3.			Unknown
	HLISTED
	Text:			Do the hospitalists on staff at your hospital admit patients from your ED?
	1.			Yes
	2.			No
	3.			Unknown
	PAYHITH
	Text:			Medicare and Medicaid offer incentives to practices that demonstrate “meaningful use of health IT”. Does your hospital have plans to apply for these incentive payments?
				1. Yes, we already applied 2. Yes, we intend to apply 3. Uncertain if we will apply 4. No, we will not apply
	PAYDR
	Text:			In which year did you first apply for meaningful use payments?
	1.			2011
	2.			2012
	PAYYR
	Text:			In which year do you expect to apply for the meaningful use payments?
	1.			2012
	2.			2013 or later
	3.			Unknown
	PERMPART
	Text:			As I mentioned earlier, I would like to discuss the plan for conducting the study.  This hospital has been assigned to a 4-week data collection period beginning on Monday, (Reporting period begin date). First, I would like to discuss the steps needed to obtain approval for the study. Are there any additional steps needed to obtain permission for the hospital to participate in the study?
	1.			Yes
	2.			No
	PERMPARTSPEC
	Text:			Specify the necessary steps needed to obtain permission for the hospital      to participate in the study      Include the name, address, phone and title of the person(s) who can grant approval
	PERM_THANK
	Text:			Thank you for your help.
	RO_PERMISSION
	Text:			Call the Regional Office to inform them of the additional steps needed to     obtain permission
	VSREPPER
	Text:			Now I would like to make arrangements to obtain the information needed for sampling. I will need to (know/verify) how your (emergency department and/or outpatient department and/or ambulatory surgery location) (is/are) organized and obtain an estimate of the number of patient visits expected during the 4-week reporting period.  Would you prefer I (get/verify) this information from you or someone else?
	1.			Respondent
	2.			Someone else
	CWHO
	Text:			What is the name of the person I should talk to?                             Alternate Contacts
	1.			Existing Contact
	2.			New Contact
	3.			Continue interview
	CINFO
	Text:			What is the name of the person I should talk to?            Enter 1 to enter/update contact person information
	1.			New contact
	2.			Continue interview
	THANK_RESP
	Text:			Thank current respondent for his/her time and cooperation
	CONTACT_DEPT
	Text:			(All eligible departments are complete. Enter 9 to wrap up the case./All eligible departments are compete or refusals. Press F10 if you plan to follow up. Department    Status ED      (Elig /Partial /Elig (refusal) / Partial (refusal) / Cmplt / Inelig) OPD   (Elig /Partial /Elig (refusal) / Partial (refusal) / Cmplt / Inelig) ASL    (Elig /Partial /Elig (refusal) / Partial (refusal) / Cmplt / Inelig)
	1.			ED
	2.			OPD
	3.			ASL
	4.			Department refusal
	5.			Department callback
	9.			Wrap up case
	WHICH_DEPT
	Text:			Which department (is refusing/are you setting a callback for)?
	1.			ED
	2.			OPD
	3.			ASC
	INTRO_ED
	Text:			If necessary, introduce yourself and explain the survey        Explain that in order to develop a sampling plan, you would like to collect more specific information about this hospital's emergency department
	ESA_NUM
	Text:			**  Show only  **
	DEL_ESA
	Text:			(Does (ESA name) still exist and is it still operational?)   (Enter 97 to delete this ESA / If No, Enter 97 to delete If Yes, Press ENTER to move to the next row)
	ESA_NAME
	Text:			(What is the name of the (first/next) emergency service area? /Are there any other emergency service areas?)          Enter 999 for no more
	ESA_TYPE
	Text:			? [F1]   What type of ESA is (ESA name)
	1.			General
	2.			Adult
	3.			Pediatric
	4.			Urgent care/Fast track
	5.			Psychiatric
	6.			Other
	ESA_EVISITS
	Text:			What is the expected number of visits from (Reporting period begin date) to (Reporting period end date) for (ESA name)?
	TWICELY
	Text:			Is the number of expected visits to any of the ESAs more than twice the     number shown on the previous sampling plan?                    ESA            Visits      Visits Previous         ESA_NAME       ESA_VISITS  I_ESA_VISITS
	1.			Yes
	2.			No
	TWICELY_SPEC
	Text:			Specify why visits have increased this year or were too low the last time     the ED participated
	HALFLY
	Text:			Is the number of expected visits to any of the ESAs less than half of the     number of visits shown on the previous sampling plan?                ESA          Visits        Visits Previous         ESA_NAME     ESA_VISITS    I_ESA_VISITS
	1.			Yes
	2.			No
	HALFLYSPEC
	Text:			Specify why visits have decreased this year or were too high the last        time the ED participated
	EBILLRECE
	Text:			Now I would like to ask you some questions about your ED. Does your ED submit any CLAIMS  electronically (electronic billing)?
	1.			Yes
	2.			No
	3.			Unknown
	EINSELIGE
	Text:			Does your ED verify an individual patient's insurance eligibility electronically, with results returned immediately?        Read answer categories out loud
	1.			Yes, with a stand-alone practice management system
	2.			Yes, with an EMR/EHR system
	3.			Yes, using another electronic system
	4.			No
	5.			Unknown
	EMEDRECE
	Text:			Does your ED use an electronic MEDICAL record (EMR) or electronic HEALTH record (EHR) system?  Do not include billing record systems.   Read answer categories out loud
	1.			Yes, all electronic
	2.			Yes, part paper and part electronic
	3.			No
	4.			Unknown
	EHRINSYRE
	Text:			In which year did your ED install the EMR/EHR system?
	EHRNAME
	Text:			What is the name of your current EMR/EHR system?
	1.			Allscripts
	2.			Cerner
	3.			eClinicalWorks
	4.			Epic
	5.			GE/Centricity
	6.			Greenway Medical
	7.			McKesson/Practice Partner
	8.			NextGen
	9.			Sage
	10.			Other - Specify
	11.			Unknown
	EHRNAME_SP
	Text:			Enter name of EMR/EHR system
	EHRINSE
	Text:			Does your ED have plans for installing a new EMR/EHR system within the next 18 months?
	1.			Yes
	2.			No
	3.			Maybe
	4.			Unknown
	EDEMOGE
	Text:			6 Indicate whether your ED has each of the following computerized capabilities.  Does your ED have a computerized system for:    Recording patient history and demographic information?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	EPROLSTE
	Text:			Does this include a patient problem list?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	EPNOTESE
	Text:			Indicate whether your ED has each of the following computerized capabilities.  Does your ED have a computerized system for:    Recording clinical notes?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	EMEDALGE
	Text:			Do they include a comprehensive list of the patient's medications and allergies?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	ECPOEE
	Text:			Indicate whether your ED has each of the following computerized capabilities.  Does your ED have a computerized system for:    Ordering prescriptions?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	ESCRIPE
	Text:			Are prescriptions sent electronically to the pharmacy?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	EWARNE
	Text:			Are warnings of drug interactions or contraindications provided?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	EREMINDE
	Text:			Indicate whether your ED has each of the following computerized capabilities.  Does your ED have a computerized system for:  Providing reminders for guideline-based interventions or screening tests?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	ECTOEE
	Text:			Indicate whether your ED has each of the following computerized capabilities.  Does your ED have a computerized system for:    Ordering lab tests?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	EORDERE
	Text:			Are orders sent electronically?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	ESETSE
	Text:			Indicate whether your ED has each of the following computerized capabilities.  Does your ED have a computerized system for:    Providing standard order sets related to a particular condition    or procedure?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	ERESULTE
	Text:			Indicate whether your ED has each of the following computerized capabilities.  Does your ED have a computerized system for:     Viewing lab results?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	EIMGRESE
	Text:			Indicate whether your ED has each of the following computerized capabilities.  Does your ED have a computerized system for:    Viewing imaging results?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	EQOCE
	Text:			Indicate whether your ED has each of the following computerized capabilities.  Does your ED have a computerized system for:    Viewing data on quality of care measures?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	EIMMREGE
	Text:			Indicate whether your ED has each of the following computerized capabilities.  Does your ED have a computerized system for:    Electronic reporting to immunization registries?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	ESUME
	Text:			Indicate whether your ED has each of the following computerized capabilities.  Does your ED have a computerized system for:    Providing patients with clinical summaries for each visit?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	EMSGE
	Text:			Indicate whether your ED has each of the following computerized capabilities.  Does your ED have a computerized system for:    Exchanging secure messages with patients?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	EHRWHOE
	Text:			At your ED, if orders for prescriptions or lab tests are submitted electronically, who submits them?      Read answer categories out loud           Enter all that apply, separate with commas
	1.			Prescribing practitioner
	2.			Other
	3.			Prescriptions and lab test orders not submitted electronically
	4.			Unknown
	EXCHSUME
	Text:			Do you share any patient health information electronically (not fax) with other providers, including hospitals, ambulatory providers, or labs?        Read answer categories out loud
	1.			Yes
	2.			No
	EXCHSUM1E
	Text:			How do you electronically share patient health information?      Read answer categories out loud     Enter all that apply, separate with commas
	1.			EHR/EMR
	2.			Web portal (separate from EHR/EMR)
	3.			Other electronic method: ___________________
	OBSUNITS
	Text:			Does your ED have a physically separate observation or clinical decision unit?
	1.			Yes
	2.			No
	3.			Unknown
	OBSDECMD
	Text:			What type of physicians make decisions for patients in this observation or clinical decision unit?      Read answer categories out loud     Enter all that apply, separate with commas
	1.			ED physicians
	2.			Hospitalists
	3.			Other physicians
	4.			Unknown
	BOARD
	Text:			Are admitted ED patients ever "boarded" for more than 2 hours in the ED or the observation unit while waiting for an inpatient bed?
	1.			Yes
	2.			No
	3.			Unknown
	BOARDHOS
	Text:			If the ED is critically overloaded, are admitted ED patients ever "boarded" in inpatient hallways or in another space outside the ED?
	1.			Yes
	2.			No
	3.			Unknown
	AMBDIV
	Text:			Did your ED go on ambulance diversion in TOTHRDIV_FILL?
	1.			Yes
	2.			No
	3.			Unknown
	TOTHRDIV
	Text:			What is the total number of hours that your hospital's ED was on ambulance diversion in TOTHRDIV_FILL?      Enter CTRL-D if data not available
	REGDIV
	Text:			Is ambulance diversion actively managed on a regional level versus each hospital adopting diversion if and when it chooses?
	1.			Yes
	2.			No
	3.			Unknown
	ADMDIV
	Text:			Does your hospital continue to admit elective or scheduled surgery cases when the ED is on ambulance diversion?
	1.			Yes
	2.			No
	3.			Unknown
	NUMSTATX
	Text:			As of last week, how many standard treatment spaces did your ED have? Standard treatment spaces are beds or treatment spaces specifically designed for ED patients to receive care, including asthma chairs.               Enter CTRL-D if data not available
	NUMOTHTX
	Text:			As of last week, how many other treatment spaces did your ED have? Other treatment spaces are other locations where patients might receive care in the ED, including chairs, stretchers in hallways that may be used during busy times.             Enter CTRL-D if data not available
	EDSPACES
	Text:			In the last two years, did your ED increase the number of standard treatment spaces?
	1.			Yes
	2.			No
	3.			Unknown
	PHYSSPACE
	Text:			In the last two years, did your ED's physical space expand?
	1.			Yes
	2.			No
	3.			Unknown
	EXPAND
	Text:			Do you have plans to expand your ED's physical space within the next two years?
	1.			Yes
	2.			No
	3.			Unknown
	BEDREG
	Text:			7 Does your ED use -   Bedside registration?
	1.			Yes
	2.			No
	3.			Unknown
	CATRIAGE
	Text:			7 Does your ED use -   Computer-assisted triage?
	1.			Yes
	2.			No
	3.			Unknown
	FASTTRAK
	Text:			7 Does your ED use -   Separate fast track unit for nonurgent care?
	1.			Yes
	2.			No
	3.			Unknown
	EDPTOR
	Text:			7 Does your ED use -   Separate operating room dedicated to ED patients?
	1.			Yes
	2.			No
	3.			Unknown
	DASHBORD
	Text:			7 Does your ED use -   Electronic dashboard (i.e., displays updated patient information    and integrates multiple data sources)?
	1.			Yes
	2.			No
	3.			Unknown
	RFID
	Text:			7 Does your ED use -   Radio frequency identification (RFID) tracking (i.e., shows exact    location of patients, caregivers, and equipment)?
	1.			Yes
	2.			No
	3.			Unknown
	ZONENURS
	Text:			7 Does your ED use -   Zone nursing (i.e., all of a nurse's patients are located in one area)?
	1.			Yes
	2.			No
	3.			Unknown
	POOLNURS
	Text:			7 Does your ED use -   Pool nurses (i.e., nurses that can be pulled to the ED to respond to surges in demand)?
	1.			Yes
	2.			No
	3.			Unknown
	FULLCAP
	Text:			7 Does your ED use -   Full capacity protocol   (i.e., allows some admitted patients to move from the ED to inpatient corridors while awaiting a bed)?
	1.			Yes
	2.			No
	3.			Unknown
	FREDIND
	Text:			** Not Displayed **
	ESA_NUM
	Text:			** SHOW ONLY **
	ESA_NAME
	Text:			*** SHOW ONLY **
	ESA_TYPE
	Text:			** SHOW ONLY **
	1.			General
	2.			Adult
	3.			Pediatric
	4.			Urgent care/Fast track
	5.			Psychiatric
	6.			Other
	ESA_EVISITS
	Text:			** SHOW ONLY **
	ESA_ONSITE
	Text:			Is (ESA name) on-site?
	1.			Yes
	2.			No
	ESA_STRET
	Text:			What is (ESA name)'s address?
	ESA_PHONE
	Text:			What is (ESA name)'s telephone number?
	ESA_CONTACT
	Text:			Enter ESA contact person's name
	TE
	Text:			** NOT DISPLAYED **
	RS
	Text:			** NOT DISPLAYED **
	AU_TYPE
	Text:			** NON_DISPLAYED **
	INTRO_OPD
	Text:			If necessary, introduce yourself and explain the survey   Explain that in order to develop a sampling plan, you would like to collect     more specific information about this hospital's outpatient department
	CLIN_NUM
	Text:			** NOT DISPLAYED **
	DEL_CLIN
	Text:			(Does (clinic name) still exist and is it still operational?)           (Enter 97 to delete this clinic / If No, Enter 97 to delete If Yes, Press ENTER to move to the next row)
	CLIN_NAME
	Text:			NHAMCS-124, 7 - 12 (What is the name of the (first/next) clinic? /Are there any other clinics?)              Enter 999 for no more. Enter XXX if clinic is not listed
	CLIN_GROUP
	Text:			What is (Clinic Name)'s specialty group?
	1.			General Medicine
	2.			Surgery
	3.			Pediatrics
	4.			Obstetrics/Gynecology
	5.			Substance Abuse
	6.			Other
	7.			Out of scope
	CLIN_EVISITS
	Text:			What is the expected number of visits from (Reporting period begin date) to (Reporting period end date) for (Clinic Name)?
	I_CLIN
	Text:			** Not Displayed **
	CLIN_EVISITS_TOTAL
	Text:			** Not Displayed **
	TOTALCLIN
	Text:			** Not Displayed **
	TOTVSOP
	Text:			** Not Displayed **
	MORECLINSPEC
	Text:			List clinics that have opened or should have been included previously
	TWICECLINSPEC
	Text:			Explain why visits have increased this year or were too low previously
	LESSCLINSPEC
	Text:			There are fewer clinics this year than in previous panel      Specify which clinics have closed or should not have been included      previously
	HALFCLINSPEC
	Text:			Specify why visits have decreased this year or were too high last year
	EBILLRECO
	Text:			Does your OPD submit any CLAIMS electronically (electronic billing)?
	1.			Yes
	2.			No
	3.			Don't know
	EINSELIGO
	Text:			Does your OPD verify an individual patient's insurance eligibility electronically, with results returned immediately?         Read answer categories out loud
	1.			Yes, with a stand-alone practice management system
	2.			Yes, with an EMR/EHR system
	3.			Yes, using another electronic system
	4.			No
	5.			Unknown
	EMEDRECO
	Text:			Does your OPD use an electronic MEDICAL record (EMR) or electronic HEALTH record (EHR) system?  Do not include billing record systems.   Read answer categories out loud
	1.			Yes, all electronic
	2.			Yes, part paper and part electronic
	3.			No
	4.			Unknown
	EHRINSYRO
	Text:			In which year did your OPD install your EMR/EHR system?
	EHRNAMO
	Text:			What is the name of your current EMR/EHR system?
	1.			Allscripts
	2.			Cerner
	3.			eClinicalWorks
	4.			Epic
	5.			GE/Centricity
	6.			Greenway Medical
	7.			McKesson/Practice Partner
	8.			NextGen
	9.			Sage
	10.			Other - Specify
	11.			Unknown
	EHRNAMO_SP
	Text:			What is the name of your current EMR/EHR system?
	EHRINSO
	Text:			Does your OPD have plans for installing a new EMR/EHR system within the next 18 months?
	1.			Yes
	2.			No
	3.			Maybe
	4.			Unknown
	EDEMOGO
	Text:			Indicate whether your OPD has each of the following computerized capabilities.  Does your OPD have a computerized system for:     Recording patient history and demographic information?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	EPROLSTO
	Text:			Does this include a patient problem list?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	EPNOTESO
	Text:			Indicate whether your OPD has each of the following computerized capabilities.  Does your OPD have a computerized system for:     Recording clinical notes?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	EMEDALGO
	Text:			Do they include a comprehensive list of the patient's medications and allergies?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	ECPOEO
	Text:			Indicate whether your OPD has each of the following computerized capabilities.  Does your OPD have a computerized system for:     Ordering Prescriptions?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	ESCRIPO
	Text:			Are prescriptions sent electronically to the pharmacy?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	EWARNO
	Text:			Are warnings of drug interactions or contraindications provided?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	EREMINDO
	Text:			Indicate whether your OPD has each of the following computerized capabilities.  Does your OPD have a computerized system for:     Providing reminders for guideline-based interventions or screening    tests?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	ECTOEO
	Text:			Indicate whether your OPD has each of the following computerized capabilities.  Does your OPD have a computerized system for:     Ordering lab tests?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	EORDERO
	Text:			Are orders sent electronically?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	ESETSO
	Text:			Indicate whether your OPD has each of the following computerized capabilities.  Does your OPD have a computerized system for:     Providing standard order sets related to a particular condition    or procedure?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	ERESULTO
	Text:			Indicate whether your OPD has each of the following computerized capabilities.  Does your OPD have a computerized system for:     Viewing lab results?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	EIMGRESO
	Text:			Indicate whether your OPD has each of the following computerized capabilities.  Does your OPD have a computerized system for:     Viewing imaging results?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	EQOCO
	Text:			Indicate whether your OPD has each of the following computerized capabilities.  Does your OPD have a computerized system for:     Viewing data on quality of care measures?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	EIMMREGO
	Text:			Indicate whether your OPD has each of the following computerized capabilities.  Does your OPD have a computerized system for:     Electronic reporting to immunization registries?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	ESUMO
	Text:			Indicate whether your OPD has each of the following computerized capabilities.  Does your OPD have a computerized system for:      Providing patients with clinical summaries for each visit?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	EMSGO
	Text:			Indicate whether your OPD has each of the following computerized capabilities.  Does your OPD have a computerized system for:     Exchanging secure messages with patients?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	EHRWHOO
	Text:			At your OPD, if orders for prescriptions or lab tests are submitted electronically, who submits them?      Read answer categories out loud      Enter all that apply, separate with commas
	1.			Prescribing practitioner
	2.			Other
	3.			Prescriptions and lab test orders are not submitted electronically
	4.			Unknown
	EXCHSUMO
	Text:			Does your OPD exchange patient clinical summaries electronically with any other providers?
	1.			Yes
	2.			No
	EXCHSUM1O
	Text:			How does your OPD electronically send or receive patient clinical summaries?       Read answer categories out loud     Enter all that apply, separate with commas
	1.	EHR/EMR
	2.	Web portal (separate from EHR/EMR)
	3.	Other electronic method: ___________________
	CLIN_NUM
	Text:			** NOT DISPLAYED **
	SAMPLED
	Text:			** Not Displayed **
	CLIN_NUM
	Text:			** SHOW ONLY **
	CLIN_NAME
	Text:			*** SHOW ONLY **
	CLIN_GROUP
	Text:			** SHOW ONLY **
	1.			General Medicine
	2.			Surgery
	3.			Pediatrics
	4.			Obstetrics/Gynecology
	5.			Substance Abuse
	6.			Other
	7.			Out of scope
	CLIN_EVISITS
	Text:			** SHOW ONLY **
	CLIN_STRET
	Text:			What is (Clinic Name)'s address?            Enter number and street.
	CLIN_STRET2
	Text:			What is (Clinic Name)'s address?            Enter the second line of address or press enter if same/none
	CLIN_CITY
	Text:			What is (Clinic Name)'s address?           Enter city
	CLIN_STATE
	Text:			What is (Clinic Name)'s address?           Enter state
	CLIN_ZIP
	Text:			What is (Clinic Name)'s address?          Enter zip code
	CLIN_PHONE
	Text:			What is (Clinic Name)'s telephone number?
	CLIN_PHTYP
	Text:			Enter phone type
	1.			Home
	2.			Work
	3.			Mobile
	4.			Pager, Beeper, Answering Service
	5.			Public Pay Phone
	6.			Toll Free
	7.			Other
	8.			Fax
	9.			Unknown
	CLIN_CONTACT
	Text:			Enter clinic director/contact person's name
	TE
	Text:			** NOT DISPLAYED **
	RS
	Text:			** NOT DISPLAYED **
	AU_TYPE
	Text:			** NON_DISPLAYED **
	I_OPDMIN
	Text:			** Not displayed **
	I_OPDMAV
	Text:			** Not displayed **
	I_TOTCLIN
	Text:			** Not displayed **
	TOT_GOODCLIN
	Text:			** NOT Displayed **
	ASL_INTRO
	Text:			To develop the sampling plan, I would like to (collect/verify) more specific information about this facility's ambulatory surgery (centers/locations). We are only interested in the following types of (centers/locations): General or main operating rooms                 Endoscopy rooms Dedicated ambulatory surgery rooms          Cardiac catheterization labs Satellite operating rooms                               Laser procedures rooms Cystoscopy rooms                                           Pain block rooms
	1.			Continue
	2.			No in-scope locations
	ASL_NUM
	Text:			** SHOW ONLY **
	DEL_ASL
	Text:			(Does (ASL name) still exist and is it still operational?)         (Enter 97 to delete this ASL/ASL entered by mistake/ If Yes, Press ENTER to move to the next row If No, Enter 97 to delete )
	ASL_NAME
	Text:			[?]  F1 ( What is the name of the (first/next) ambulatory surgery location? /Are there any other ambulatory surgery locations?)        Enter only IN_SCOPE (ASCs/ASLs)   (Press F1 for in-scope (centers/locations))          Include any (ASCs/ASLs) that are located in satellite facilities          Enter 999 for no more
	ASL_SPEC_GRP
	Text:			What is ASL Name's specialty group?
	1.			General
	2.			Multi-specialty
	3.			Gastroenterology
	4.			Ophthalmology
	5.			Orthopedics
	6.			Pain Block
	7.			Plastic Surgery
	8.			Ear, Nose and Throat
	9.			Obstetrics - Gynecology
	10.			Urology
	11.			Other specialty
	ASL_EVISITS
	Text:			What is the expected number of ambulatory (outpatient) surgery cases for ASL Name from (Reporting period begin date) to (Reporting period end date)?
	I_ASL
	Text:			** Not Displayed **
	TOT_GOODASL
	Text:			** NOT Displayed **
	ANYMORE_ASLS
	Text:			The max of 15 (ASCs/ASLs) were entered.      Are there any more (ASCs/ASLs)?
	1.			Yes
	2.			No
	EXTRA_ASLS
	Text:			How many other (ASCs/ASLs) are there?
	TOT_GOODASL2
	Text:			** NOT Displayed **
	CHECK_EVISITS
	Text:			You have indicated that none of your ambulatory surgery (centers/locations) will be seeing patients from (Reporting period begin date) to (Reporting period end date). Is that correct?
	1.			Yes
	2.			No
	THANK_INELIG
	Text:			Since there are no in-scope ambulatory surgery (centers/locations) for (facility name), it should not have been chosen for our survey. Thank you very much for your cooperation.
	ASCLISTA
	Text:			Now I have some questions about generating a report for all ambulatory surgery patients for sampling. Would you or your IT staff be able to generate a single list of ambulatory surgery cases for any of the following (centers/locations)?  (Name of all ASLs)
	1.			Yes
	2.			No - ONLY 2 LOGS
	3.			No - More than 2 logs
	ASCLISTB
	Text:			For which of these (centers/locations) can lists be combined?          Enter all that apply, separate with commas
	1.			ASL_NAME [1]
	2.			ASL_NAME [2]
	3.			ASL_NAME [3]
	4.			ASL_NAME [4]
	5.			ASL_NAME [5]
	6.			ASL_NAME [6]
	7.			ASL_NAME [7]
	8.			ASL_NAME [8]
	9.			ASL_NAME [9]
	10.			ASL_NAME [10]
	11.			ASL_NAME [11]
	12.			ASL_NAME [12]
	13.			ASL_NAME [13]
	14.			ASL_NAME [14]
	15.			ASL_NAME [15]
	IT_CNAME
	Text:			What is the name of the IT contact?
	IT_CTITLE
	Text:			What is (IT contact name)'s title?
	IT_CSTRET
	Text:			What is (IT contact name)'s address?          Enter number and street or press enter if same
	IT_CSTRET2
	Text:			What is (IT contact name)'s address?          Enter second line of address or press enter for none/same
	IT_CCITY
	Text:			What is (IT contact name)'s address?           Enter city or press enter if same
	IT_CSTATE
	Text:			What is (IT contact name)'s address?         Enter state or press enter if same
	IT_CZIP
	Text:			What is (IT contact name)'s address?         Enter zip code or press enter if same
	IT_CPHONE
	Text:			What is (IT contact name)'s phone number?
	IT_CPHTYP
	Text:			Enter phone typ
	1.			Home
	2.			Work
	3.			Mobile
	4.			Pager, Beeper, Answering Service
	5.			Public Pay Phone
	6.			Toll Free
	7.			Other
	8.			Fax
	9.			Unknown
	UPDATE_BCONTACTS
	Text:			** Not Displayed **
	ASL_NUM
	Text:			** SHOW ONLY **
	ASL_NAME
	Text:			** SHOW ONLY **
	AU_NUMBER
	Text:			Assign AU number     Assign the same AU number to each (center/location) where the ambulatory surgery cases can be combined into the one listing.
	EBILLRECA
	Text:			Does your (ASC/ambulatory surgery location) submit any CLAIMS electronically (electronic billing)?
	1.			Yes
	2.			No
	3.			Don't know
	EINSELIGA
	Text:			Does your (ASC/ambulatory surgery location) verify an individual patient's insurance eligibility electronically, with results returned immediately?           Read answer categories
	1.			Yes, with a stand-alone practice management system
	2.			Yes, with an EMR/EHR system
	3.			Yes, using another electronic system
	4.			No
	5.			Unknown
	EMEDRECA
	Text:			Does your (ASC/ambulatory surgery location) use an electronic MEDICAL record (EMR) or electronic HEALTH record (EHR) system?  Do not include billing record systems.      Read answer categories out loud
	1.			Yes, all electronic
	2.			Yes, part paper and part electronic
	3.			No
	4.			Unknown
	EHRINSYRA
	Text:			In which year did your (ASC/ambulatory surgery location) install your EMR/EHR system?
	EHRNAMA
	Text:			What is the name of your current EMR/EHR system?
	1.			Allscripts
	2.			Cerner
	3.		eClinicalWorks
	4.		Epic
	5.		GE/Centricity
	6.		Greenway Medical
	7.		McKesson/Practice Partner
	8.		NextGen
	9.		Sage
	10.		Other - Specify
	11.		Unknown
	EHRNAMA_SP
	Text:			What is the name of your current EMR/EHR system?
	EHRINSA
	Text:			Does your (ASC/ambulatory surgery location) have plans for installing a new EMR/EHR system within the next 18 months?
	1.			Yes
	2.			No
	3.			Maybe
	4.			Unknown
	EDEMOGA
	Text:			Indicate whether your (ASC/ambulatory surgery location) has each of the following computerized capabilities. Does your (ASC/ambulatory surgery location) have a computerized system for:            Recording patient history and demographic information?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	EPROLSTA
	Text:			Does this include a patient problem list?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	EPNOTESA
	Text:			Indicate whether your (ASC/ambulatory surgery location) has each of the following computerized capabilities. Does your (ASC/ambulatory surgery location) have a computerized system for:           Recording clinical notes?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	EALLERGA
	Text:			Do they include a comprehensive list of the patient's medications and allergies?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	ECPOEA
	Text:			Indicate whether your (ASC/ambulatory surgery location) has each of the following computerized capabilities. Does your (ASC/ambulatory surgery location) have a computerized system for:           Ordering Prescriptions?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	ESCRIPA
	Text:			Are prescriptions sent electronically to the pharmacy?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	EWARNA
	Text:			Are warnings of drug interactions or contraindications provided?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	EREMINDA
	Text:			Indicate whether your (ASC/ambulatory surgery location) has each of the following computerized capabilities. Does your (ASC/ambulatory surgery location) have a computerized system for:           Providing reminders for guideline-based interventions or screening tests?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	ECTOEA
	Text:			Indicate whether your (ASC/ambulatory surgery location) has each of the following computerized capabilities. Does your (ASC/ambulatory surgery location) have a computerized system for:           Ordering lab tests?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	EORDERA
	Text:			Are orders sent electronically?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	ESETSA
	Text:			Indicate whether your (ASC/ambulatory surgery location) has each of the following computerized capabilities. Does your (ASC/ambulatory surgery location) have a computerized system for:           Providing standard order sets related to a particular condition or procedure?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	ERESULTA
	Text:			Indicate whether your (ASC/ambulatory surgery location) has each of the following computerized capabilities. Does your (ASC/ambulatory surgery location) have a computerized system for:           Viewing lab results?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	EIMGRESA
	Text:			Indicate whether your (ASC/ambulatory surgery location) has each of the following computerized capabilities. Does your (ASC/ambulatory surgery location) have a computerized system for:           Viewing imaging results?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	EQOCA
	Text:			Indicate whether your (ASC/ambulatory surgery location) has each of the following computerized capabilities. Does your (ASC/ambulatory surgery location) have a computerized system for:           Viewing data on quality of care measures?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	EIMMREGA
	Text:			Indicate whether your (ASC/ambulatory surgery location) has each of the following computerized capabilities. Does your (ASC/ambulatory surgery location) have a computerized system for:           Electronic reporting to immunization registries?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	ESUMA
	Text:			Indicate whether your (ASC/ambulatory surgery location) has each of the following computerized capabilities. Does your (ASC/ambulatory surgery location) have a computerized system for:           Providing patients with clinical summaries for each visit?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	EMSGA
	Text:			Indicate whether your (ASC/ambulatory surgery location) has each of the following computerized capabilities. Does your (ASC/ambulatory surgery location) have a computerized system for:           Exchanging secure messages with patients?
	1.			Yes, used routinely
	2.			Yes, but not used routinely
	3.			No
	4.			Unknown
	EHRWHOA
	Text:			At your (ASC/ambulatory surgery location), if orders for prescriptions or lab tests are submitted electronically, who submits them?            Read answer categories out loud.    Enter all that apply, separate with commas
	1.			Prescribing practitioner
	2.			Other
	3.			Prescriptions and lab test orders are not submitted electronically
	4.			Unknown
	EXCHSUMA
	Text:			Do you share any patient health information electronically (not fax) with other providers, including hospitals, ambulatory providers, or labs?
	1.			Yes
	2.			No
	EXCHSUMMCA
	Text:			How do you electronically share patient health information?      Read answer categories out loud     Enter all that apply, separate with commas
	1.			EHR/EMR
	2.			Web portal (separate from EHR/EMR)
	3.			Other electronic method: ___________________
	PAYHITA
	Text:			Medicare and Medicaid offer incentives to practices that demonstrate “meaningful use of health IT”. Does your hospital have plans to apply for these incentive payments?
				1. Yes, we already applied 2. Yes, we intend to apply 3. Uncertain if we will apply 4. No, we will not apply
	PAYDRA
	Text:			In which year did you first apply for meaningful use payments?
	1.			2011
	2.			2012
	PAYYRA
	Text:			In which year do you expect to apply for the meaningful use payments?
	1.			2012
	2.			2013 or later
	3.			Unknown
	ASL_EVISITS
	Text:			** SHOW ONLY **
	ASL_ONSITE
	Text:			Is ASL Name on-site?
	1.			Yes
	2.			No
	ASL_STRET
	Text:			What is ASL Name's address or the address where the abstractions will be done?             Enter number and street.
	ASL_STRET2
	Text:			What is ASL Name's address or the address where the abstractions will be done?            Enter the second line of address or press enter if same/none
	ASL_CITY
	Text:			What is ASL Name's address or the address where the abstractions will be done?           Enter city.
	ASL_STATE
	Text:			What is ASL Name's address or the address where the abstractions will be done?           Enter state.
	ASL_ZIP
	Text:			What is ASL Name's address or the address where the abstractions will be done?          Enter zip code.
	ASL_PHONE
	Text:			What is ASL Name's telephone number or the telephone number where the abstractions will be done?
	ASL_CONTACT
	Text:			Enter ambulatory surgery (center/location) contact person's name
	EXIT_REFUSAL
	Text:			Are you exiting this case because of a refusal?
	1.			Yes
	2.			No
	CALLBACKNOTES
	Text:			I'd like to schedule a DATE to (conduct/complete) the interview. What DATE AND TIME would be best to visit again?            Today is:  ^IntDate
	THANKCB
	Text:			Thank you. I will call/come back at the time suggested       Revisit   (Callback information)
	FOLLOW_UP
	Text:			The following departments have refused. Do you plan to follow-up on these department(s)?
	1.			Yes, will follow-up on department(s)
	2.			No , wrap case up
	CALLBACKNOTES
	Text:			I'd like to schedule a DATE to (conduct/complete) the interview. What DATE AND TIME would be best to visit again?    Today is:  ^IntDate
	THANKCB
	Text:			Thank you. I will call/come back at the time suggested   Revisit   (Callback information)
	THANKYOU
	Text:			This concludes the interview.  Thank you for your patience, and for taking the time to answer our questions.
	SET_REINT
	Text:			** Non Displayed **
	HOSPREF
	Text:			**  Not displayed **
	ELIGED
	Text:			Does this hospital have an eligible ED?
	1.			Yes
	2.			No
	VSED101
	Text:			Enter number of expected visits for the ED
	VSEDLY
	Text:			Enter the number of visits to the department last year
	ELIGOPD
	Text:			Does this hospital have an eligible OPD?
	1.			Yes
	2.			No
	VSOPD101
	Text:			Enter number of expected visits for this OPD.
	VSOPDLY
	Text:			Enter number of OPD visits last year
	ELIGASC
	Text:			Does this hospital have an eligible ambulatory surgery center?
	1.			Yes
	2.			No
	VSASC101
	Text:			Enter number of expected visits
	VSASCLY
	Text:			Enter number of ambulatory surgery visits last year
	WHOMHOSP
	Text:			By whom?
	1.			Hospital administrator
	2.			Approval board or official
	3.			Other hospital official
	WHOMED
	Text:			By whom?
	1.			Hospital administrator
	2.			ED/OPD/Ambulatory Surgery Director
	3.			Approval board or official
	4.			Other hospital official-Specify
	WHOMOP
	Text:			By whom?
	1.			Hospital administrator
	2.			ED/OPD/Ambulatory Surgery Director
	3.			Approval board or official
	4.			Other hospital official-Specify
	WHOMAS
	Text:			By whom?
	1.			Hospital administrator
	2.			ED/OPD/Ambulatory Surgery Director
	3.			Approval board or official
	4.			Other hospital official-Specify
	WHOMHOSPSPEC
	Text:			Specify the name of the other hospital official who refused for the hospital
	WHOMEDSPEC
	Text:			Specify the name of the other hospital official who refused for the ED
	WHOMOPSPEC
	Text:			Specify the name of the other hospital official who refused for the OPD
	WHOMASSPEC
	Text:			Specify the name of the other hospital official who refused for the ASL
	TELPERHO
	Text:			Was the refusal by telephone or in person for the hospital?
	1.			Telephone
	2.			In person
	TELPERED
	Text:			Was the refusal by telephone or in person for the ED?
	1.			Telephone
	2.			In person
	TELPEROP
	Text:			Was the refusal by telephone or in person for the OPD?
	1.			Telephone
	2.			In person
	TELPERAS
	Text:			Was the refusal by telephone or in person for the ASL?
	1.			Telephone
	2.			In person
	REASON
	Text:			Specify what reason was given for the refusal/breakoff   Specify if hospital, ED, OPD. or Ambulatory Surgery Location
	CONVHOSP
	Text:			Was conversion attempted?
	1.			Yes
	2.			No
	CONVED
	Text:			Was conversion attempted?
	1.			Yes
	2.			No
	CONVOP
	Text:			Was conversion attempted?
	1.			Yes
	2.			No
	CONVAS
	Text:			Was conversion attempted?
	1.			Yes
	2.			No

29