Physician

Attachment n

2010 PHYSICIAN QUESTIONNAIRE

THIS PAGE INTENTIONALLY BLANK

T he Office of Minority Health Survey

National Survey of U.S. Public’s Awareness of Racial and Ethnic Health Disparities

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0335. The time required to complete this information collection is estimated to average 15 minutes per response, 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 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

DIRECTIONS

Thank you for agreeing to participate in this survey.

For each question, please choose the answer that best applies to you. If you are not able to find an answer that fits exactly, choose the one that comes closest.

These questions can be answered by simply marking the box next to the response that best fits your answer.

We appreciate you taking the time to contribute to this important study.

Physician reporting burden for this collection of information is estimated to average 15 minutes per response, excluding the time for reviewing instructions, 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.

OMB Control No: 0990-0335
Expiration Date: 03/31/2012

The first few questions ask about your practice and public health information.

1. How would you describe the practice where you see most of your patients (i.e., your main practice)?

General hospital

Private practice

Teaching hospital

Local health department

Community health clinic

Campus health center

Other, specify

2. What percentage of your current patients are (check only one percentage for each group):

Item	1 10% or less	2 11- 25%	3 26-50%	4 Over 50%
a. White/Caucasian, Non-Hispanic	1	2	3	4
b. Black or African American	1	2	3	4
c. Hispanic/Latino	1	2	3	4
d. Asian American/Pacific Islander	1	2	3	4
e. Other	1	2	3	4

3. In the last year, have you heard or read anything about racial and ethnic disparities in health and health care in America?

Yes (If yes, briefly describe which you have heard or read)

No

4. Have you ever heard of any of the following public health campaigns or read any of the following publications? (Check all that apply)

a. The US Dept. of Health and Human Services’ Healthy People 2010

b. The Agency for Healthcare Research and Quality’s National Healthcare Disparities Report

c. The Institute of Medicine’s 2003 report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care

d. The Office of Minority Health’s National Partnership for Action

e. The PBS Documentary, Unnatural Causes: Is Inequality Making Us Sick?

5. Does the organization where you currently practice offer the following (check all that apply):

a. Training for your staff using OMH’s Cultural Competency Curriculum Modules (CCCMs)

If yes, have you personally participated in any training on the CCCMs?

b. Language assistance services (i.e., bilingual staff, interpreter services)

c. Easy to understand patient-related materials in the languages of the commonly encountered groups in your service area

d. Signs in the languages of the commonly encountered groups in your service area

For the next few questions, please think about African Americans in our country today.

6. Do you think the average African American is better off, just as well off, or worse off as the average white person in terms of:

Item	1 Better off	2 Just as well off	3 Worse off
a. getting needed health care?	1	2	3
b. infant mortality?	1	2	3
c. life expectancy?	1	2	3
d. how healthy they are?	1	2	3
e. getting routine medical care when they need it?	1	2	3
f. getting specialized treatments or surgery when they need it?	1	2	3
g. having health insurance?	1	2	3

7. Do you think the average African American is more likely, just as likely, or less likely to be diagnosed with any of the following health conditions as the average white person?

Item	1 More likely	2 Just as likely	3 Less likely
a. Auto Immune Deficiency Disorder (AIDS) or the HIV virus	1	2	3
b. Cancer (all types including cancer of the stomach, prostate, or bladder)	1	2	3
c. Hypertension	1	2	3
d. Diabetes	1	2	3

8. When going to a doctor or health clinic for health care services, do you think most African Americans receive a higher quality of health care, the same quality of health care, or a lower quality of health care as most whites?

1. Higher quality

2. Same quality

3. Lower quality

9. How big a problem do you think each of the following issues is for the average African American? Is it a major problem, a minor problem, or not a problem at all for the average African American?

Item	1 Major problem	2 Minor problem	3 Not a problem at all
a. being able to afford the cost of health insurance and necessary medical care	1	2	3
b. having enough doctors and other health providers near where they live	1	2	3
c. having difficulty getting care because of their race or ethnic background	1	2	3

Now, thinking about Hispanics or Latinos in our country today,

10. Do you think the average Hispanic/Latino is better off, just as well off, or worse off as the average white person in terms of:

Item	1 Better off	2 Just as well off	3 Worse off
a. getting needed health care?	1	2	3
b. infant mortality?	1	2	3
c. life expectancy?	1	2	3
d. how healthy they are?	1	2	3
e. getting routine medical care when they need it?	1	2	3
f. getting specialized treatments or surgery when they need it?	1	2	3
g. having health insurance?	1	2	3

11. Do you think the average Hispanic/Latino is more likely, just as likely, or less likely to be diagnosed with any of the following health conditions as the average white person?

Item	1 More likely	2 Just as likely	3 Less likely
a. Auto Immune Deficiency Disorder (AIDS) or the HIV virus	1	2	3
b. Cancer (all types including cancer of the stomach, prostate, or bladder)	1	2	3
c. Hypertension	1	2	3
d. Diabetes	1	2	3

12. When going to the doctor or health clinic for health care services, do you think most Hispanics/Latinos receive a higher quality of health care, the same quality of health care, or a lower quality of health care as most whites?

1 Higher quality

2 Same quality

3 Lower quality

13. How big a problem do you think each of the following issues is for the average Hispanic/Latino? Is it a major problem, a minor problem, or not a problem at all for the average Hispanic/Latino?

Item	1 Major problem	2 Minor problem	3 Not a problem at all
a. being able to afford the cost of health insurance and necessary medical care	1	2	3
b. having enough doctors and other health providers near where they live	1	2	3
c. having difficulty getting care because of their race or ethnic background	1	2	3

Now, thinking about Asian Americans/Pacific Islanders in our country today,

14. Do you think the average Asian American/Pacific Islander is better off, just as well off, or worse off as the average white person in terms of:

Item	1 Better off	2 Just as well off	3 Worse off
a. getting needed health care?	1	2	3
b. infant mortality?	1	2	3
c. life expectancy?	1	2	3
d. how healthy they are?	1	2	3
e. getting routine medical care when they need it?	1	2	3
f. getting specialized treatments or surgery when they need it?	1	2	3
g. having health insurance?	1	2	3

15. Do you think the average Asian American/Pacific Islander is more likely, just as likely, or less likely to be diagnosed with any of the following health conditions as the average white person:

Item	1 More likely	2 Just as likely	3 Less likely
a. Auto Immune Deficiency Disorder (AIDS) or the HIV virus	1	2	3
b. Cancer (all types including cancer of the stomach, prostate, or bladder)	1	2	3
c. Hypertension	1	2	3
d. Diabetes	1	2	3

16. When going to the doctor or health clinic for health care services, do you think most Asian American/Pacific Islanders receive a higher quality of health care, the same quality of health care, or a lower quality of health care as most whites?

1 Higher quality

2 Same quality

3 Lower quality

17. How big a problem do you think each of the following issues is for the average Asian American/Pacific Islander? Is this a major problem, a minor problem, or not a problem at all for the average Asian American/Pacific Islander?

Item	1 Major problem	2 Minor problem	3 Not a problem at all
a. being able to afford the cost of health insurance and necessary medical care	1	2	3
b. having enough doctors and other health providers near where they live	1	2	3
c. having difficulty getting care because of their race or ethnic background	1	2	3

These last questions are designed to help us better understand the doctors who participate in our survey.

18. Are you male or female?

1 Male

2 Female

19. What is your age?

20. Are you yourself of Hispanic, Latino or Spanish origin?

1 Yes

2 No

21. What is your race?

1 White

2 Black or African American

3 Asian American/ Pacific Islander

4 Other, specify

THANK YOU!

Thank you very much for completing the questionnaire. The information you have provided will be useful to policymakers. If you have anything else to add, or any questions, please call toll-free 1-877-236-8161. Please reference “Office of Minority Health Interview”. Again, thank you for your participation.

PLEASE RETURN THE COMPLETED QUESTIONNAIRE IN THE POSTAGE-PAID ENVELOPE, OR FAX THE SURVEY TO: 1-312-759-4852.