Draft 2-10-12
SURVEY OF PRIMARY CARE PHYSICIANS ON ORAL HEALTH
TELEPHONE SCREENER
1. Hello, have I reached Dr. {PHYSICIAN NAME}’s office?
YES 1 (GO TO 4)
NO 2
WRONG NUMBER 3
NO LONGER WORKS HERE 4 (GO TO 3)
DECEASED 5 (END STATEMENT 1)
RETIRED 6 (END STATEMENT 1)
NOT IN PRACTICE 7 (END STATEMENT 1)
NOT AVAILABLE DURING FIELD PERIOD 8 (END STATEMENT 1)
REFUSED -7
2. I’m trying to reach the office of Dr. {PHYSICAN’S NAME} on {STREET} in {CITY, STATE}. Do you know {him/her}?
[IF NEEDED: Do you know {his/her} telephone number/address/the name of a person who might know how to reach {him/her}?]
YES 1 (FOLLOW LEADS, THEN RESTART)
NO 2 (END STATEMENT 1, THEN TO TRACING)
3. Do you have a forwarding telephone number and address for the doctor?
[IF NEEDED: Do you know the name of a person who might know how to reach {him/her}?]
YES 1 (FOLLOW LEADS, THEN RESTART)
NO 2 (END STATEMENT 1, THEN TO TRACING)
4. This is {INTERVIEWER NAME}. I am calling on behalf of the Office on Women’s Health at the Department of Health and Human Services regarding a study of physicians. Is Dr. {PHYSICIAN NAME}’s specialty {SPECIALTY}?
YES 1 (GO TO 6)
NO 2
REFUSED -7 (GO TO 6)
DON’T KNOW -8 (GO TO 6)
5. What is {his/her} specialty?
FAMILY PRACTICE/FAMILY MEDICINE 1
INTERNAL MEDICINE/GENERAL INTERNAL MEDICINE/INTERNIST 2
OTHER, SPECIFY 91 (END STATEMENT 2)
REFUSED -7
DON’T KNOW -8
6. I’d like to confirm that I have the correct name for Dr. {PHYSICIAN’S NAME}.
[VERIFY SPELLING AND RECORD ANY CHANGES.]
FIRST NAME ______________________________
MIDDLE NAME/INITIAL ______________________
LAST NAME_______________________________
JR/SR/III__________________________________
REFUSED -7
DON’T KNOW -8
7. I’d like to confirm that I have the correct office address for Dr. {PHYSICIAN’S NAME}.
[VERIFY ADDRESS AND RECORD ANY CHANGES.]
PRACTICE/CLINIC NAME__________________________
STREET ADDRESS_______________________________
PO BOX/SUITE/ROOM/DEPT/BLDG___________________
CITY, STATE ZIP _________________________________
REFUSED -7
DON’T KNOW -8
8. Does {PHYSICIAN’S NAME} see all {his/her} patients in an urgent or immediate care center?
[IF NEEDED: All patients or only some patients?]
YES 1 (END STATEMENT 2)
NO 2
REFUSED -7
DON’T KNOW -8
9. Does {PHYSICIAN’S NAME} see all {his/her} patients in a Federal facility such as a VA office, a military clinic, or a Public Health Service or Indian Health Service clinic?
[IF NEEDED: All patients or only some patients?]
YES 1 (END STATEMENT 2)
NO 2
REFUSED -7
DON’T KNOW -8
10. [TO BE ASKED ONLY IF LOAD FILE INDICATES THIS MAY BE RELEVANT]
Does Dr. {PHYSICIAN’S NAME} see all {his/her} patients in a nursing home, rehabilitation center or correctional facility?
[IF NEEDED: All patients or only some patients?]
YES 1 (END STATEMENT 2)
NO 2
REFUSED -7
DON’T KNOW -8
11. Is {PHONE NUMBER} the best phone number at which to reach Dr. {PHYSICIAN’S NAME}’s office?
[VERIFY AND RECORD ANY CHANGES]
TELEPHONE NUMBER _____________________________________ (END STATEMENT 2)
REFUSED -7 (END STATEMENT 2)
DON’T KNOW -8 (END STATEMENT 2)
END STATEMENT 1: Thank you for your time.
END STATEMENT 2: Those are all the questions I have for you. Thank you for your help.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | HINTS 2007 Main Instrument |
| Author | Chantell Atere |
| File Modified | 0000-00-00 |
| File Created | 2021-01-30 |