Form #1 Form #1 Intake reporting form - web version

CONSUMER REPORTING SYSTEM FOR PATIENT SAFETY: INTAKE FORM- WEB VERSION

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

PROGRAMMER GENERAL INSTRUCTIONS:

REFER TO FILE “IntroductoryPagesWebsite11thFeb2013” FOR INTRO TEXT ON WEBSITE.

INTRODUCTORY PAGE: (OPEN TO ANYONE WHO GOES TO THE WEBSITE TO SEEK INFORMATION).

IF THEY OPT TO “SUBMIT A REPORT” CONSUMERS HAVE OPTION OF

A) ENTERING EMAIL ADDRESS/PASSWORD SO THEY CAN COMPLETE REPORT IN MULTIPLE SESSION, OR

B) COMPLETE IT WITHOUT REGISTERING AS LONG AS THEY ACCEPT TERMS.

ONCE THEY ARE LOGGED INTO THE CONSUMER REPORT:

WITHIN EACH MODULE, DO NOT DISPLAY THE QUESTION NUMBERS ON THE SCREEN.

THE QUESTION NUMBERS SHOULD BE USED AS THE “VARIABLE LABEL” WHEN OUTPUTTING AND CREATING CODEBOOK FOR THE RESEARCH TEAM.

RESPONDENTS CAN SKIP ANY QUESTION THEY DO NOT WISH TO COMPLETE.

NO NEED TO PROGRAM ANY POP UP THAT SAYS THEY’VE LEFT SOMETHING BLANK.

UNLESS SPECIFICED OTHERWISE, “PLEASE CHECK ALL THAT APPLY”

OPTIONS SHOULD BE CODED AS “1” IF CHECKED OR AS “0” IF NOT CHECKED.

PROGRAMMER: PROGRAM AS FIRST SCREEN ON CRSPS INTAKE FORM:

Table: 3-1

SECTION 1: INTRODUCTION

The Consumer Reporting System for Patient Safety (CRSPS) allows patients and their families to voluntarily report on the safety of their health care. “Safety concerns” include medical mistakes and negative effects. Negative effects can be physical or emotional and they may include infections, drug reactions, or other complications. Safety concerns might come up during a visit to a doctor’s office, at a pharmacy, or in the hospital.

Complaints about services like food or parking should not be reported here. Please refer to the resources link on the home page for where to report those in your area.

It should take about 20-25 minutes to complete a report. You may skip any question by leaving it blank. The more information you provide, the more we can learn from your experience.

You will have the option to give permission for the Consumer Reporting System for Patient Safety staff to share your report with any doctor, nurse, or other health care provider (or facility) that was involved in the negative effect. This would alert the facility’s staff so they can learn about what went wrong and improve safety.

1

Public reporting burden for this collection of information is estimated to average 25 minutes per response, the estimated time required to complete the survey. 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.

.1 Who is the patient with a safety concern? PROGRAMMER NOTE: SELECT 1

□_A Me

□_B A child

□_C A spouse, domestic partner or other family member (for example, a grandparent, aunt, etc.)

□_D A friend

□_E A patient or client

□_F Someone else  [DISPLAY AS TEXT BOX: Who is the patient? ALLOW 50]

1. In what city and state did the safety concern occur?

Enter the city: (ALLOW 25)

Enter the State: (HAVE DROP DOWN MENU WITH LIST OF STATES)

PROGRAMMER NOTE: MODULE/SECTION 2 TO START ON NEXT SCREEN

Table: 3-2

SECTION 2: DESCRIPTION OF YOUR SAFETY CONCERN

2.1 Please tell us about the safety concern.

PROGRAMMER NOTE: HAVE FREE TEXT BOXES WITH FOLLOWING FIELDS. ALLOW 250 CHARACTERS PER TEXT BOX.

2.1a. What happened?

2.1b. Where did it happen?

2.1c. When did it happen?

2.1d. Why did it happen?

2.2 What is the name of the patient?

ENTER FIRST NAME:

ENTER LAST NAME:

Now we will ask some questions to make sure we understand what happened.

2.3 In your opinion, did a doctor, nurse, or other health care provider make a medical mistake or error in the patient’s care? PROGRAMMER NOTE: SELECT 1

PROGRAMMER: PROGRAM FOLLOWING TEXT AS POP-UP:

POP UP: A medical mistake or error is something that was done (or not done) by a health care provider that would be considered incorrect at the time it happened. Sometimes medical mistakes can result in harm or injury to the patient, but not every time.

□_A Yes  GO TO 3.1

□_B No  GO TO 2.3.1

□_C Don’t know  GO TO 2.3.1

**When people are harmed or injured as a result of medical care, we call this a negative effect. Negative effects can be physical or emotional and they may include infections, drug reactions, or other complications.

2.3.1 Did a negative effect take place as a result of the patient’s care?

□_A Yes  GO TO 4.1

□_B No  GO TO 2.3.1.1

□_C Don’t know  GO TO 2.3.1.1

2.3.1.1 You told us that a mistake did not take place (or that you don’t know) and that a negative effect did not take place (or that you don’t know). Is this correct?

□_A Yes  GO TO 6.1

□_B No  GO TO 6.1

_C Don’t know  GO TO 6.1

Table: 3-3

PROGRAMMER NOTE: SECTION 3 TO BE ASKED ONLY IF ITEM 2.2=YES. IF RESPONSE IS “NO” OR “DON’T KNOW” SKIP TO SECTION 4.

SECTION 3: MISTAKE

3.1 Did the medical mistake or error involve any of the following? Please choose the one answer that fits best.

□_A A mistake related to a medicine

[PROGRAM FOLLOWING TEXT AS POP UP: Medicines can include prescription or non-prescription medication, herbs, dietary supplements, vaccines, contrast dye or other injected medicines]  GO TO 3.1.1.1

□_B A mistake related to a test, procedure, or surgery

[PROGRAM FOLLOWING TEXT AS POP UP: This includes tests that involve taking samples of skin or tissue, inserting tubes to examine internal parts of your body, or other tests involving blood, urine, or X-rays.]  GO TO 3.1.2.1

□_C A mistake related to pregnancy or childbirth

[PROGRAM FOLLOWING TEXT AS POP UP: This includes errors in diagnostic testing during pregnancy and errors during labor and delivery]  GO TO 3.2

□_D A mistake related to a diagnosis or advice from a doctor, nurse, or other health care provider  GO TO 3.1.3.1

□_E A mistake related to poor cleanliness or poor hygiene  GO TO 3.2

□_F Something else, or more than one mistake [GO TO 3.1f1]

3.1.f1 What was the mistake?

PROGRAMMER: PROGRAM AS TEXT BOX. ALLOW MAX 250  GO TO 3.2

3.1.1.1 As best as you can, please name or describe the medicine. [PROGRAMMER NOTE: PROGRAM FREE TEXT BOX. ALLOW 50.]

3.1.1.2 Was it a prescription medicine? PROGRAMMER NOTE: SELECT 1

[PROGRAM AS POP UP: Don’t include over-the-counter medicines that you can buy without a prescription from a doctor or nurse.]

□_A Yes

□_B No

□_C Don’t know

3.1.1.3 Did the mistake with medicine involve any of the following? Please choose the one answer that fits best.

□_A Wrong medicine GO TO 3.2

□_B Wrong dose GO TO 3.2

□_C Something else [GO TO 3.1.1.3-OTHER: What did the mistake involve? FREE TEXT BOX, ALLOW 50. GO TO 3.2]

3.1.2.1 As best as you can, please name or describe the test, procedure, or surgery.

[PROGRAMMER: PROGRAM FREE TEXT BOX, ALLOW 100]

3.1.2.2 Did the mistake with a test, procedure, or surgery involve any of the following? PLEASE CHECK ALL THAT APPLY.

PROGRAMMER: FOR EACH ITEM CHECKED, CODE AS “1”. DEFAULT WILL BE “0” IF LEFT BLANK.

□_A Wrong patient [POP UP: The patient was not correctly identified.]

□_B Wrong test, procedure, or surgery [POP UP: The wrong type of test, procedure, or surgery was done.]

□_C Wrong part of the body [POP UP: The test, procedure, or surgery was on the wrong part of the body.]

□_D A mistake was made during the test, procedure, or surgery

□_E The test, procedure, or surgery was delayed

□_F The test results were lost and the patient did not receive them

□_G The patient developed an infection

□_H A problem with anesthesia

□_I Something else [What did the mistake involve? [FREE TEXT BOX. ALLOW 50]

 GO TO 3.2 ONCE ITEMS CHECKED

3.1.3.1 In your opinion, what was the mistake with the diagnosis or medical advice?

[PROGRAMMER NOTE: PROGRAM FREE TEXT BOX.]

3.2 Where did the mistake happen? Please choose the one answer that fits best.

□_A In a doctor’s office or a clinic

□_B In a pharmacy

□_C In the emergency department

□_D In a hospital

□_E At home

□_F Somewhere else [Where? FREE TEXT BOX]

□_G Don’t know

3.3 Would you like to tell us the name and address of the health care doctor, nurse, or other health care provider (or the health care facility) involved in the mistake? PROGRAMMER NOTE: SELECT 1

□_A Yes

□_B Yes, but I do not know the name and address of the provider  GO TO 3.4

□_C No, I do not know the name and address of the provider  GO TO 3.4

□_D No, I do not want to tell you  GO TO 3.4

3.3.1 Please write the name and address of the health care provider (or facility) involved in the mistake. [PROGRAMMER: PROGRAM FOLLOWING FREE TEXT BOXES]

NAME OF PROVIDER/ HEALTH CARE FACILITY: TEXT BOX. ALLOW 50

STREET ADDRESS: TEXT BOX ALLOW 50

CITY: TEXT BOX ALLOW 25

STATE: DISPLAY SCROLL DOWN BOX WITH STATES LISTED IN ALPHA ORDER

3.3.2 Was a second health care provider (or facility) involved? PROGRAMMER NOTE: SELECT 1

□_A Yes

□_B No GO TO 3.3.5

3.3.3 Would you like to tell us the name and address of the second health care provider (or facility) involved in the mistake?

□_A Yes

□_B Yes, but I do not know the name and address of the provider  GO TO 3.3.5

□_C No, I do not know the name and address of the provider  GO TO 3.3.5

□_D No, I do not want to tell you  GO TO 3.3.5

3.3.4 Please write the name and address of the second health care provider (or facility) involved in the mistake. [FREE TEXT BOX]

NAME OF PROVIDER/ HEALTH CARE FACILITY:

TEXT BOX. ALLOW 50

STREET ADDRESS: TEXT BOX ALLOW 50

CITY: TEXT BOX ALLOW 25

STATE: DISPLAY SCROLL DOWN BOX WITH STATES LISTED IN ALPHA ORDER

You have the option to give permission for the Consumer Reporting System for Patient Safety staff to share your report with any doctor, nurse, or other health care provider (or facility) that was involved in the mistake. This would alert the facility’s staff so they can learn about what went wrong and improve safety.

3.3.5 May we share your report with the health care provider (or facility) you identified? PROGRAMMER NOTE: SELECT 1

□_A Yes

□_B No

3.4 In what month and year did the mistake happen? (Your best estimate is fine.)

ENTER MONTH: PROGRAM SCROLL DOWN WITH MONTHS LISTED

ENTER YEAR: PROGRAM SCROLL DOWN WITH YEARS LISTED (ALLOW 10 YEARS BEFORE ACTUAL YEAR)

3.5 Did a doctor, nurse, or other health care provider tell you the mistake happened?

□_A YesGO TO 3.7

□_B No

3.5.1 How did you find out that the mistake happened? [PROGRAMMER NOTE: PROGRAM FREE TEXT BOX.]

Sometimes medical mistakes affect patients financially. For example, patients may have to miss work, pay for extra tests or procedures, or take additional trips to a health care facility.

3.6 Did the mistake affect the patient financially? PROGRAMMER NOTE: SELECT 1

□_A Yes

□_B No

□_C Don’t know

When people are harmed or injured as a result of medical care, we call this a negative effect. Negative effects can be physical or emotional and they may include infections, drug reactions, or other complications.

3.7 Did the patient experience any negative effects as a result of the mistake or error? PROGRAMMER NOTE: SELECT 1

□_A Yes

□_B No  GO TO 5.1

□_C Don’t know  GO TO 5.1

Table: 3-4

SECTION 4: NEGATIVE EFFECT

PROGRAMMER NOTE: IF QUESTION XXX = 2.2=YES, SUPPRESS ALL INTROS AND QUESTIONS BELOW THAT HAVE AN ASTERISK. CONSUMER SHOULD NOT BE ASKED THOSE QUESTIONS:

IF QUESTION 2.2 WAS “NO” OR “DON’T KNOW” OR LEFT BLANK ( WAS NOT ANSWERED) THEN ALL QUESTIONS IN THIS MODULE SHOULD BE ASKED.

**

4.1 **Did the negative effect involve any of the following? Please choose the one answer that fits best.

□_A A negative effect related to a medicine

□_B A negative effect related to a test, procedure, or surgery

□_C A negative effect related to pregnancy or childbirth

□_D A negative effect related to a diagnosis or medical advice

□_E Unclean or unsanitary care

□_F Something else or more than one negative effect [What did it involve? FREE TEXT BOX. ALLOW 100]

4.2 What kind of negative effect did the patient experience? PROGRAMMER NOTE: SELECT 1

□_A Physical

□_B Emotional  GO TO 4.4

□_C Both

4.3 What kind of physical negative effect did the patient experience? PLEASE CHECK ALL THAT APPLY.

□_A Dizziness

□_B Sick to the stomach (nausea)

□_C Infection

□_D Pain

□_E A fall that caused an injury

□_F Open sores on skin

□_G A sexual problem

□_H Blood clot

□_I Uncontrolled bleeding

□_J Breathing difficulty

□_K Numbness or weakness

□_L Injury to teeth

□_M Injury to an eye

□_N Burn

□_O Heart attack or stroke

□_P Other physical effect [Please describe. FREE TEXT BOX. ALLOW 100]

□_Q The negative effect was not physical.

4.4 **Where did the negative effect first happen? Please choose the one answer that fits best.

□_A In a doctor’s office or a clinic

□_B In a pharmacy

□_C In the emergency department

□_D In a hospital

□_E At home

□_F Somewhere else [Where did this first happen? PROGRAM TEXT BOX, ALLOW 50]

□_G Don’t know

4.5 **Would you like to tell us the name and address of the doctor, nurse, or other health care provider (or health care facility) involved in the negative effect? PROGRAMMER NOTE: SELECT 1

□_A Yes

□_B Yes, but I do not know the name and address of the provider  GO TO 4.6

□_C No, I do not know the name and address of the provider  GO TO 4.6

□_D No, I do not want to tell you  GO TO 4.6

4.5.1 **Please write the name and address of the health care provider (or facility) involved in the negative effect. [PROGRAM FOLLOWING TEXT BOXES]

NAME OF PROVIDER/ HEALTH CARE FACILITY: ALLOW 50

ADDRESS: ALLOW 25

CITY: ALLOW 25

STATE: HAVE DROP DOWN MENU WITH ALPHA LISTING OF STATE

ZIP CODE: ALLOW 5

4.5.2 **Was another health care provider (or facility) involved? PROGRAMMER NOTE: SELECT 1

□_A Yes

□_B NoGO TO 4.5.5

4.5.3 Would you like to tell us the name and address of the second health care provider (or facility) involved in the negative effect?

□_A Yes

□_B Yes, but I do not know the name and address of the provider  GO TO 4.6

□_C No, I do not know the name and address of the provider  GO TO 4.6

□_D No, I do not want to tell you  GO TO 4.6

4.5.4 **Please write the name and address of the second health care provider (or facility) involved in the negative effect. [PROGRAM FOLLOWING FREE TEXT BOXES]

NAME OF PROVIDER/ HEALTH CARE FACILITY: ALLOW 50

ADDRESS: ALLOW 25

CITY: ALLOW 25

STATE: HAVE DROP DOWN MENU WITH ALPHA LISTING OF STATE

ZIP CODE: ALLOW 5

**You have the option to give permission for the Consumer Reporting System for Patient Safety staff to share your report with any doctor, nurse, or other health care provider (or facility) that was involved in the negative effect. This would alert the facility’s staff so they can learn about what went wrong and improve safety.

4.5.5 **May we share your report with the health care provider (or facility) you identified? PROGRAMMER NOTE: SELECT 1

□_A Yes

□_B No

4.6 **In what month and year did the negative effect happen? (Your best estimate is fine.)

ENTER MONTH: HAVE DROP DOWN MENU WITH MONTHS LISTED

YYYY: HAVE DROP DOWN MENU WITH LAST 10 YEARS LISTED INCLUDING CURRENT ONE

4.7 Did the patient get additional medical testing or treatment because of the negative effect? PROGRAMMER NOTE: SELECT 1

□_A Yes

□_B No

□_C Don’t know

4.8 How did the patient find out that the negative effect happened? Please choose the one answer that fits best.

□_A The patient noticed it.

□_B A friend or family member noticed it and told the patient.

□_C A doctor, nurse, or other health care provider told the patient about it.

□_D An administrator or manager told the patient about it

□_E The patient found out in some other way.  [How did patient find out? FREE TEXT BOX. ALLOW 100]

□_F The patient never knew about it.

4.9 Did a doctor, nurse, or other health care provider make any special effort to help the patient handle the negative effect? PROGRAMMER NOTE: SELECT 1

□_A Yes

□_B No  GO TO 4.10

□_C Don’t know  GO TO 4.10

4.9.1 How helpful were they? PROGRAMMER NOTE: SELECT 1

□_A Extremely helpful

□_B Very helpful

□_C Somewhat helpful

□_D Slightly helpful

□_E Not at all helpful

4.10 Did the negative effect cause the patient to miss work, school, or other regular activities? PROGRAMMER NOTE: SELECT 1

□_A Yes

□_B No

□_C Don’t know

**Sometimes patients experience negative financial effects. For example, patients may have to miss work, pay for extra testing or treatment, or take additional trips to a health care facility.

4.11 **Did the negative effect cause financial problems for the patient? PROGRAMMER NOTE: SELECT 1

□_A Yes

□_B No

□_C Don’t know

Table: 3-5

SECTION 5: CONTRIBUTING FACTORS, CHANGES IN CARE,

DISCOVERY, & REPORTING

Now we will ask some questions about why the mistake or negative effect happened, and what the patient did afterward.

5.1 In your opinion, could anything have been done differently to prevent this mistake or negative effect from happening? PROGRAMMER NOTE: SELECT 1

□_A Yes [What could have been done? PROGRAM FREE TEXT BOX. ALLOW 100]

□_B No

□_C Don’t know

5.2 Why do you think this mistake or negative effect happened?

PROGRAMMER: PROGRAM FREE TEXT BOX.

5.3 In your opinion, did any of the following lead to the mistake or negative effect? PLEASE CHECK ALL THAT APPLY.

PROGRAMMER NOTE: ALL CHECKED ITEMS SHOULD GET A CODE OF 1. ALL NON-CHECKED SHOULD DEFAULT TO “0”.

Communication with doctors, nurses or other health care providers

5.3.1 Was it because the doctors, nurses, or other health care providers…

□_A did not listen to the patient?

□_B did not explain things to the patient in the patient’s language?

□_C used terminology the patient could not understand?

□_D did not spend enough time with the patient?

□_E spoke with an accent that was hard to understand?

□_F ignored what the patient told them?

□_G did not explain medications or their side effects?

□_H did not explain follow up care instructions?

Responsiveness of staff

5.3.2 Was it because of not getting…

□_A help as soon as the patient needed it?

□_B a referral as soon as the patient needed it?

□_C an appointment as soon as the patient needed it?

□_D care as soon as the patient needed it?

Coordination of care

5.3.3 Was it because…

□_A the doctors, nurses, or other health care providers were not aware of care that took place someplace else?

□_B of the lack of follow up by the doctors, nurses, or other health care providers?

□_C doctors, nurses, or other health care providers did not seem to work well together as a team?

Access

5.3.4 Was it because the patient…

□_A was not able to get in to see a specialist for care?

□_B was not able to get the tests or treatments that the patient believed necessary?

□_C was not able to get the tests or treatments that a provider believed necessary?

□_D did not get help or advice they needed?

Verification

5.3.5 Was it because someone did not…

□_A correctly identify the patient?

□_B have the most recent and up-to-date information about the patient?

Other

5.3.6 Was it because the patient…

□_A couldn’t afford the care the patient believed necessary?

□_B couldn’t afford the care a provider believed necessary?

□_C had no insurance to pay for the care the patient believed necessary?

□_C had no insurance to pay for the care a provider believed necessary?

5.4 Did this mistake or negative effect cause the patient to switch to a different doctor, nurse, or other health care provider, or transfer to a different medical facility? PLEASE CHECK ALL THAT APPLY.

PROGRAMMER NOTE: CODE EACH BOX CHECK OFF AS “1”. ALL NON-CHECKED RESPONSES SHOULD DEFAULT TO “O”

□_A Yes – Switched to a different health care provider

□_B Yes – Transferred to a different hospital

□_C Yes – Transferred to a different pharmacy

□_D Yes – Other [What was the switch? FREE TEXT BOX. ALLOW 50]

□_E No – There was no change

5.5 Did the patient tell anyone about the mistake or negative effect? PROGRAMMER NOTE: SELECT 1

□_A Yes

□_B No  GO TO 6.1

□_C Don’t know  GO TO 6.1

5.5.1 Who did the patient tell about the mistake or negative effect? PLEASE CHECK ALL THAT APPLY.

PROGRAMMER NOTE: ALL CHECKED ITEMS GET CODE OF “1” ALL THAT ARE NOT CHECKED GET CODE OF “0”

□_A A family member or friend

□_B A doctor, nurse, or other health care provider

□_C A health care administrator or manager

□_D Someone at the pharmacy

□_E A minister or other religious leader

□_F A lawyer

□_G Someone else  GO TO 5.5.1other

5.5.1other Who did the patient tell?

PROGRAMMER: PROGRAM FREE TEXT BOX.[ ALLOW 50]

Table: 3-6

SECTION 6: CLINICIAN/FACILITY & PATIENT INFORMATION

A member of the Consumer Reporting System for Patient Safety staff can follow up by telephone. Please give us your name and how to reach you. We will make sure that your name and other contact information is kept secure. It will be shared only with your permission. If you decide NOT to give us your contact information, we will not contact you in the future.

6.1 May we contact you if we need more information? PROGRAMMER NOTE: SELECT 1

□_A Yes

□_B No  GO TO 6.2

6.1.1 Please tell us your name and your address, telephone number, or email.

My name: PROGRAMMER ALLOW 50

My address: PROGRAM STREET ADDRESS (50),

CITY (25),

STATE (DO AS DROP DOWN MENU),

ZIPCODE (ALLOW 5)

My phone number: PROGRAMMER: FORMAT AS (XXX) XXX-XXXX

This is my… PROGRAMMER NOTE: SELECT MULTIPLE

□_A Home number

□_B Work number

□_C Cell number

My email address:

PROGRAMMER: PROGRAM AS ___________@____.____

6.1.2 Is it better to reach you on weekdays or weekends? PROGRAMMER NOTE: SELECT 1

□_A Weekday

□_B Weekend

6.1.3 What is the best time of day to reach you? PROGRAMMER NOTE: SELECT 1

□_A Morning

□_B Afternoon

□_C Evening

[PROGRAMMER: DISPLAY 6.1.4 ONLY IF ANSWER TO 3.3.5 OR 4.5.5= YES. OTHERWISE SKIP]

6.1.4 When we contact the doctor, nurse, or other health care provider (or facility) to share your report, may we include your name and contact information? This will help the provider or facility match your report with their records. The provider or facility will not contact you.

□_A Yes

□_B No

Our last questions will help us to understand whether some people are more likely than others to experience medical mistakes and negative effects.

6.2 What is the patient’s sex?

□_A Male

□_B Female

6.3 At the time of the mistake or negative effect, approximately how old was the patient?

Age of patient at time of mistake or negative effect: [ALLOW 3]

Note: If the patient was a child and less than 1 year, enter 1 year.

PROGRAMMER NOTE: RANGE 1-99

6.4 Is the patient Hispanic, Latino/a, or Spanish origin? (One or more categories may be selected)

□_A No

□_B Yes, Mexican, Mexican American, Chicano/a

□_C Yes, Puerto Rican

□_D Yes, Cuban

□_E Yes, another Hispanic, Latino, or Spanish Origin

6.5 What is the patient’s race? (One or more categories may be selected)

□_A White

□_B Black or African American

□_C American Indian or Alaska Native

□_D Asian Indian

□_E Chinese

□_F Filipino

□_G Japanese

□_H Korean

□_I Vietnamese

□_J Other Asian

□_K Native Hawaiian

□_L Guamanian or Chamorro

□_M Samoan

□_N Other Pacific Islander

□_O Vietnamese

6.6 [TBD: Add an additional question about race/ethnicity tailored to the demographics of the specific community]

6.7 What type of health insurance did the patient have at the time of the mistake or negative effect? Please choose the one answer that fits best.

□_A Private insurance through an employer

□_B Private insurance that the patient bought

□_C Medicare

□_D Medicaid (including Medicaid managed care plans)

□_E Other  6.7eTYPE

□_F Not insured (Please select this only if you have not picked any other answer)

□_G Don’t know

□_H I do not wish to disclose this information.

6.7eTYPE What other type of health insurance did patient have?

[DISPLAYED ONLY IF 6.7E WAS CHECKED.

PROGRAM FREE TEXT BOX. ALLOW 50]

6.8 How did you learn about the Consumer Reporting System for Patient Safety? Please choose the one answer that fits best.

□_A A doctor, nurse, or other health care provider’s website

□_B A flyer or poster in a doctor’s office, clinic, hospital, emergency department, pharmacy, or other health care facility

□_C A computer kiosk in a doctor’s office, clinic, hospital, emergency department, pharmacy, or other health care facility

□_D A conversation with a doctor, nurse, or other health care provider

□_E Mailed materials from a doctor, nurse, or other health care provider

□_F Other [How did you learn about the system? [FREE TEXT BOX. ALLOW 100]

>THANKS<

Thank you for your report and for helping to improve patient safety.

PROGRAMMER NOTE: PLEASE PROGRAM STANDARD EXIT SCREEN TO ALLOW R TO CONFIRM THAT THEY WISH TO SUBMIT THEIR REPORT AND GET CONFIRMATION T HAT THEIR PATIENT SAFETY EVENT WAS SUBMITTED.

PROGRAMMER NOTE: PLEASE ADD STANDARD WINDOW TO ALLOW RESPONDENT TO HIT BUTTONS TO DOWNLOAD, PRINT AND/OR SAVE THEIR REPORT AS PDF DOCUMENT.