NCS-FS_PBS Provider Substitution Form_2012-07-06

PSU ID:
Provider ID:

PSU Name:
Provider Name:

PBS Provider Substitution Form
Instructions: For each provider location that requires substitution, please fill out this form as completely as possible. When
submitting, please include an electronic version of the contact log for the location. Send completed forms and supporting
documentation to [email protected].

Primary Contact Person Information
Name:
Telephone:

Role/Position:
Email:

Reason for Substitution
Location is out-of-scope: Yes
No
Out-of-scope description:
No longer offers prenatal care
Practice dissolved into existing practices
Solo practitioner retired or otherwise stopped practicing
Other:
Source of information leading to out-of-scope determination:
Location has other reason for substitution: Yes
No
Description of other reason (e.g. cannot get IRB clearance):

Location is a refusal: Yes
No
Number of refusals:
Soft Refusal(s)
Hard Refusal(s)
Hostile Refusal
Total number of contact attempts for location:
Refusal letter sent? Yes
No
PI refusal conversion attempt? Yes
No
Other refusal conversion efforts (please describe):
Name of primary source of refusal:
Role of primary source of refusal:

Key Dates
Date provider recruitment began:

Date of final contact:

For Field Support/Westat Usage
Date submitted by SC to FS:
Date submitted by FS to Westat:

EROC included with submission: Yes
Number of refusals:

Substitute Provider ID:
Substitute Provider Address 1:
Substitute Provider Address 2:
Substitute Sample Rate of Women:

Substitute Provider Name:
Substitute Provider City:
Substitute Provider State:
Substitute Provider Zip:

No