Log sheet

0990-PatientPerspective_App I Patient recruitment log.doc

Patient Perpective of Delivery of Health Care Through the use of an Electronic Health Record Survey

Log sheet

OMB: 0955-0011

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PATIENT PERCEPTIONS OF THE DELIVERY OF HEALTH CARE

THROUGH THE USE OF AN ELECTRONIC HEALTH RECORD

Patient Recruitment Log

Interviewer Name: ___________________________ Date: ____/___/_______

Practice Name: ______________________________ Practice Location: _________________________

Practice number: _____ EHR or Paper? Sheet Number: ____ of _____ for this practice




Interviewer’s best guess

#

Time

For each patient in waiting area

Age

Gender

Race



[ ] Did not approach – Reason

[ ] Ineligible – circle one: age, new patient

[ ] Completed questionnaire, ID _______

EHR practices only, if refused survey:

[ ] Refused F.G. – Reason: _____

[ ] F.G. card number _____

Refused – Reason

[ ] Before appt., elig. unk.

[ ] Before appt., eligible

[ ] After appt., eligible

[ ] 18 - 64

[ ] 65+

[ ] Female

[ ] Male


[ ] Hisp/Latino

[ ] White

[ ] Afr Amer.

[ ] Asian

[ ] Other

Notes to remember R for after appt:





[ ] Did not approach – Reason

[ ] Ineligible – circle one: age, new patient

[ ] Completed questionnaire, ID _______

Refused – Reason

[

EHR practices only, if refused survey:

[ ] Refused F.G. – Reason: _____

[ ] F.G. card number _____

] Before appt., elig. unk.

[ ] Before appt., eligible

[ ] After appt., eligible

[ ] 18 - 64

[ ] 65+

[ ] Female

[ ] Male


[ ] Hisp/Latino

[ ] White

[ ] Afr Amer.

[ ] Asian

[ ] Other

Notes to remember R for after appt:





[ ] Did not approach – Reason

[ ] Ineligible – circle one: age, new patient

[ ] Completed questionnaire, ID _______

Refused – Reason

[

EHR practices only, if refused survey:

[ ] Refused F.G. – Reason: _____

[ ] F.G. card number _____

] Before appt., elig. unk.

[ ] Before appt., eligible

[ ] After appt., eligible

[ ] 18 - 64

[ ] 65+

[ ] Female

[ ] Male


[ ] Hisp/Latino

[ ] White

[ ] Afr Amer.

[ ] Asian

[ ] Other

Notes to remember R for after appt:





[ ] Did not approach – Reason

[ ] Ineligible – circle one: age, new patient

[ ] Completed questionnaire, ID _______

EHR practices only, if refused survey:

[ ] Refused F.G. – Reason: _____

[ ] F.G. card number _____

Refused – Reason

[ ] Before appt., elig. unk.

[ ] Before appt., eligible

[ ] After appt., eligible

[ ] 18 - 64

[ ] 65+

[ ] Female

[ ] Male


[ ] Hisp/Latino

[ ] White

[ ] Afr Amer.

[ ] Asian

[ ] Other

Notes to remember R for after appt:





[ ] Did not approach – Reason

[ ] Ineligible – circle one: age, new patient

[ ] Completed questionnaire, ID _______

Refused – Reason

[

EHR practices only, if refused survey:

[ ] Refused F.G. – Reason:_____

[ ] F.G. card number _____

] Before appt., elig. unk.

[ ] Before appt., eligible

[ ] After appt., eligible

[ ] 18 - 64

[ ] 65+

[ ] Female

[ ] Male


[ ] Hisp/Latino

[ ] White

[ ] Afr Amer.

[ ] Asian

[ ] Other

Notes to remember R for after appt:




I.3

File Typeapplication/msword
File TitlePATIENT PERCEPTIONS OF THE DELIVERY OF HEALTH CARE
AuthorPremini
Last Modified ByDHHS
File Modified2010-04-20
File Created2010-04-20

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