Checklist for Negotiating Logistics with Providers for the NCS

Checklist for Negotiating the Logistics of the NCS with Providers

Administrative Information

Name of Provider
Provider Location ID
Main point of contact
	Name:
	Phone:
Additional points of contact
	Name:
	Phone:
	Name:
	Phone:
Days of operation	☐M	☐T		☐W	☐ Th	☐ F	☐ Sa	☐ Su
Hours of operation
Days/Times of Prenatal Care Visits
Staff meetings – day and times for potential NCS training
Frequency of provider staff meetings

Prescreening and Provider Data Capabilities

Electronic/ Paper medical records system / combination
Can the provider prescreen on any of the following:
	Age (18+)				☐ Yes	☐ No
	Woman is pregnant				☐ Yes	☐ No
	First prenatal visit for this pregnancy in this provider frame				☐ Yes	☐ No
Can the provider release information without patient consent?
	Names of patients				☐ Yes	☐ No
	Addresses of patients				☐ Yes	☐ No
	Telephone numbers				☐ Yes	☐ No
Will location provide retrospective list of patients?					☐ Yes	☐ No
If building list in real time,
	Will provider build the list, identifying total number of patients?				☐ Yes	☐ No
	Could SC staff build list using records?				☐ Yes	☐ No
	Will SC staff build list by counting patients as they come in?				☐ Yes	☐ No
Can NCS staff be able to introduce the Study to the patient?					☐ Yes	☐ No
	If no, could we train your staff during staff meetings?				☐ Yes	☐ No

First Prenatal Visit

Describe steps of prenatal visit at this location (e.g., where do they check in?)
(list steps)
On average how much time does a first prenatal visit take?
(time in minutes)
What other tests are involved in this visit?
Is this a referral prenatal practice location?	☐ Yes	☐ No
Does this location accept walk-ins?	☐ Yes	☐ No

Provider Location and Research

Has this provider location conducted other research?		☐ Yes	☐ No
	If Yes, describe:
Are formal requirements/regulations/review processes required?		☐ Yes	☐ No
	If Yes, describe:
Who approves research at this practice location?
(full contact info)
Would NCS staff with security clearance fall under a HIPAA waiver?		☐ Yes	☐ No
	If Yes, describe:

Arrangements in Provider Office

Can NCS Study information be placed in the waiting room (brochures, posters)?		☐ Yes	☐ No
Is there space available at this practice location for NCS staff to talk to patients?		☐ Yes	☐ No
	If Yes, describe the available space:
Is there internet access availability at this practice location for NCS staff?		☐ Yes	☐ No
	If Yes, describe:
(For real time listing) Would we be able to set up a table with study staff in the waiting room with NCS study information and a signup sheet?		☐ Yes	☐ No
	If Yes, describe:
Is there private space available for NCS staff to speak with patients?		☐ Yes	☐ No
	If Yes, describe:

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