Provider Screening Instrument

Form Approved

OMB No. 0920-0840

Expiration Date 02/29/2016

Attachment 4
Provider Screening Instrument

Formative Research to Develop Social Marketing Campaigns: Prevention Is Care (PIC)

Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, 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 currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0840)

Formative Research to Develop Social Marketing Campaigns: Prevention Is Care (PIC)

Hello, my name is _______________ and I’m from (name of company). We are calling on behalf of RTI International, a non-profit research organization, and the Centers for Disease Control and Prevention. We are not selling or promoting any product. We are calling to recruit physicians to take part in a research study about HIV testing and prevention.

The purpose of the research is to learn physicians’ thoughts on a communication campaign being developed for health care providers and involves participating in an interview. To see if you are eligible for this study, I need to ask you some questions. If you are eligible and choose to be in the study, all of your comments will be kept private. In appreciation for your participation, you will receive $__ [INSERT AMOUNT] as a token of appreciation.

My questions will only take a few minutes. May I proceed?

1. First, does any member of your household or immediate family work for or receive any compensation from:

A market research company _____

An advertising agency or public relations firm _____

The media (TV/radio/newspapers/magazines) _____

The CDC _____

MAX. 1 OR 2  A pharmaceutical company _____

[IF “YES” TO ANY  GET SPECIFICS AND HOLD.

RECRUITMENT FACILITY SHALL CONTACT RTI TO DETERMINE WHETHER TO RECRUIT THE INDIVIDUAL]

2. Have you attended a focus group discussion or interview in the last six months about HIV? By focus group, we mean an informal, round-table discussion, conducted by a facilitator, in which you were asked your professional opinions regarding something related to HIV?

Yes		TERMINATE
No		 CONTINUE

2. Are you licensed to practice medicine in the US?

NO		TERMINATE
YES		 CONTINUE

2. Are you a MD or a DO? [Record] _______________________

[If No] (THANK/END)

2. How many years have you been practicing medicine? ______________

< 2		TERMINATE
2 or >		 CONTINUE

2. What is your specialty?

Family Medicine		 CONTINUE TO Q7A
Internal Medicine		 GO TO Q7A
Infectious Disease		 CONTINUE TO Q8
Other		TERMINATE

ASK FAMILY PRACTICE AND INTERNAL MEDICINE DOCTORS ONLY

7A. Do you have a sub-specialty?

Yes _____  Go to Q7B

No _____  CLASSIFY AS PCP AND CONTINUE TO Q8

7B. What is your sub specialty? _____________________________________

[Check all that apply]

• Adolescent medicine

• Allergy and immunology

• Cardiology

• Endocrinology

• Gastroenterology

• Geriatrics

• Hematology

• HIV Medicine

• Nephrology

• Oncology

• Pulmonology

• Rheumatology

• Sports medicine

• Other: ___________________

[IF HIV MEDICINE - CLASSIFY AS PCP] [IF ANYTHING ELSE, TERMINATE ]

8. In what setting do you see patients? (RECORD ALL THAT APPLY)

Private practice (By private practice, we mean a private physician’s office or group practice.)
Community Hospital
HMO (such as Kaiser)
Academic/University-affiliated hospital
Community Clinic/Health Center		If yes, go to 8a
Government/Military Facility
Other

8a. Does your clinic receive Ryan White funding?

No		CONTINUE
Yes		 CONTINUE

[NOTE: RECRUIT AT LEAST 4 PCPs THAT RECEIVE RYAN WHITE FUNDING]

8. In which of the following settings do you see the largest number of patients? Provide estimated percentages for each that apply.

[RECORD ALL THAT APPLY]

Private practice (By private practice, we mean a private physician’s office or group practice.)
Community Hospital
HMO (such as Kaiser)
Academic/University-affiliated hospital
Community Clinic/Health Center
Government/Military Facility
Other

[NOTE: ATTEMPT A MIX OF PUBLIC AND PRIVATE PRACTICE PHYSICIANS]

8. Approximately how many patients do you have in your current caseload?^

_________

8. Thinking about your current caseload, how many patients that you regularly see in your practice do you treat for HIV or AIDS? ________________

[FOR IDs -- MUST BE “30” OR GREATER TO QUALIFY FOR PIC SAMPLE]

[FOR PCPs –TERMINATE FROM PIC SAMPLE IF LESS THAN 20]

11a. What percentage of patients in your total caseload are HIV infected? _________*

8. Are you currently prescribing antiretroviral medications for your patients living with HIV?*

Yes		 CONTINUE
No		TERMINATE

12a. How many prescriptions do you write a month? __________^

8. Do you accept any of the following payment options? (RECORD ALL THAT APPLY)

MEDICAID
MEDICARE

8. Had you heard of the Prevention IS Care campaign before we contacted you about this study?

Yes		 SKIP TO QUESTION 14A.
No		CONTINUE

[NOTE: ATTEMPT TO RECRUIT A MIX OF PHYSICIANS WHO ARE AND ARE NOT FAMILIAR WITH THE CAMPAIGN]

14a. Are you or had you been directly involved in the campaign’s development or publicity?

Yes		TERMINATE
No		 CONTINUE – SPECIFY – How have you heard of the PIC Campaign previously? ____________________________

8. If private practice, approximately how many total of the following staff are in your private practice/office?

Nurses (RN/LPN)
Nurse Practitioners
Physician Assistants

8. What is the name of your (practice, hospital, clinic, or HMO system)?

___________________________________

8. What is the postal zip code where you primarily practice?

   Six- eight digits
   Refused

9. Please tell me your age._____________

[Terminate if less than 18, greater than 99]

[NOTE: ATTEMPT A MIX OF AGES]

8. Gender

Male
Female

[NOTE: ATTEMPT A MIX OF GENDERS]

Invitation:

Thank you for answering all of my questions. As I mentioned earlier, we are conducting a research study on behalf of the CDC regarding a communications campaign under development for providers and would like to hear your professional views. In order to hear them first-hand, we would like to invite you to take part in an informal, personal interview. The interviews are being scheduled on [DAYS/DATE TBD]. The discussion will last about 1 hour. No one will attempt to sell you anything. As a token of appreciation, you will receive [INSERT INCENTIVE AMOUNT] at the time of the interview. The interviews will be audio-recorded, and CDC staff may observe the interview. Can we schedule your attendance?

Closing for Ineligible Participants:

Thank you for answering my questions. At this time you are not eligible to be in this study because... We value your interest in this research study. Thank you for being willing to help us.

___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

note to recruiting facility – at the completion of recruitment Detach this page before returning the screeners to rti

Contact Information

Now, let me confirm the spelling of your name, address, and phone number so we can send you directions and a reminder before your scheduled interview time.

Record respondent’s information

Name: Preferred Telephone:

Address:

City, State: Zip:

If you would like, I can also send you a reminder by e-mail.

IF YES: What e-mail address should I use? ________________

If you have any questions or find that you can’t attend, please call us right away at [phone number] so that we can find a replacement. Thank you for your time and for agreeing to help with this important research study.

 Rescreening question to be confirmed prior to start of interview.



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