Form #2 Form #2 Demographic Questionnaires

Attachment 8:

Demographic Questionnaires

Table of Contents

Demographic Check-in Form for Parents/Caregivers 8-3

Demographic Check-in Form for Patients 8-5

Demographic Check-in Form for Providers 8-7

Demographic Check-in Form for Information Technology (IT) Developers 8-9

A CTION Sickle Cell Disease Focus Groups

Demographic Check-in Form

Parents/Caregivers

Thank you for participating in the sickle cell disease focus group. Before we get started, we would like to ask you to confirm a couple of pieces of basic demographic information. Your responses to these questions and your input during our discussion today will remain confidential. Your responses will be kept confidential to the extent permitted by law, including AHRQ’s confidentiality statute, 42 USC 299c-3(c). This information will help us better understand the input we gather through the focus group. Thank you in advance for your time and participation.

1. How old are you? _____________

2. Are you currently employed?

• Yes. If yes, what is your occupation? _____________________________________

• No

3. Please select the race/ethnicity category that best represents your family.

Are you Hispanic or Latino/Latina?

• No

• Yes

What is your race? Please select one or more.

• American Indian/Native American or Alaskan Native

• Asian

• Native Hawaiian or Other Pacific Islander

• Black or African American

• White

• Other ______________________

Public reporting burden for this collection of information is estimated to average 120 minutes per response, the estimated time required to complete the focus group. 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: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

Public reporting burden for this collection of information is estimated to average 120 minutes per response, the estimated time required to complete the focus group. 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: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

Public reporting burden for this collection of information is estimated to average 120 minutes per response, the estimated time required to complete the focus group. 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: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

4. What is the gender of your child who has sickle cell disease?

• Male

• Female

5. How would you rate your child’s current health?

• Excellent

• Good

• Fair

• Poor

6. What is the health insurance status of your child?

• Medicaid or public insurance

• Commercial Insurance

• Uninsured

• Don’t know/not sure

7. Where does your child receive routine sickle cell care?

_________________________________________________________________________

_________________________________________________________________________

A CTION Sickle Cell Disease Focus Groups

Demographic Check-in Form

Patients

Thank you for participating in the sickle cell disease focus group. Before we get started, we would like to ask you to confirm a couple of pieces of basic demographic information. Your responses to these questions and your input during our discussion today will remain confidential. Your responses will be kept confidential to the extent permitted by law, including AHRQ’s confidentiality statute, 42 USC 299c-3(c). This information will help us better understand the input we gather through the focus group. Thank you in advance for your time and participation.

1. How old are you? _____________

2. What grade in school are you currently in/going into? _____________

3. Please select the race/ethnicity category that best represents your family.

Are you Hispanic or Latino/Latina?

• No

• Yes

What is your race? Please select one or more.

• American Indian/Native American or Alaskan Native

• Asian

• Native Hawaiian or Other Pacific Islander

• Black or African American

• White

• Other ______________________

4. What is your gender?

• Male

• Female

5. Where do you receive routine sickle cell care?

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

A CTION Sickle Cell Disease Focus Groups

Demographic Check-in Form

Providers

Thank you for participating in the sickle cell disease focus group. Before we get started, we would like to ask you to confirm a couple of pieces of basic demographic information. Your responses to these questions and your input during our discussion today will remain confidential. Your responses will be kept confidential to the extent permitted by law, including AHRQ’s confidentiality statute, 42 USC 299c-3(c). This information will help us better understand the input we gather through the focus group. Thank you in advance for your time and participation.

1. How old are you? _____________

2. Please select the race/ethnicity category that best represents your family.

Are you Hispanic or Latino/Latina?

• No

• Yes

What is your race? Please select one or more.

• American Indian/Native American or Alaskan Native

• Asian

• Native Hawaiian or Other Pacific Islander

• Black or African American

• White

• Other ______________________

3. What is your gender?

• Male

• Female

4. What is your clinical specialty? ______________________________

5. How many years have you been practicing within this specialty? __________________

6. How would you characterize your practice? (select one)

• Pediatric care

• Adult care

• Both

7. How comfortable are you in using technology in health care (such as electronic health records)?

• Not comfortable

• Somewhat comfortable

• Very comfortable

• Expert

A CTION Sickle Cell Disease Focus Groups

Demographic Check-in Form

Information Technology (IT) Developers

Thank you for participating in the sickle cell disease focus group. Before we get started, we would like to ask you to confirm a couple of pieces of basic demographic information. Your responses to these questions and your input during our discussion today will remain confidential. Your responses will be kept confidential to the extent permitted by law, including AHRQ’s confidentiality statute, 42 USC 299c-3(c). This information will help us better understand the input we gather through the focus group. Thank you in advance for your time and participation.

1. What is your area of expertise within IT/HIT? __________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

2. Do you have experience building HIT tools for patients with chronic conditions, such as sickle cell, to help manage their care? If yes, please explain briefly. ____________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

3. What type of organization do you work for? (e.g. IT company, university, etc.) ? __________________________________________________________________________

4. What training or education did you receive for your current role in technology? (include degrees with major and any specific training relevant to HIT)

_________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

5. Do you have any potential conflicts of interest with regards to recommendations for the development of an IT-enabled tool for care transitions for patients with sickle cell disease? (circle one)

Yes No

If yes, please explain: _______________________________________________________

_________________________________________________________________________

_________________________________________________________________________

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