Form 3 Three-Month Patient Follow-up Questionnaire

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

Attachment D:

Three-Month Patient Follow-up Telephone Call

1. Introduction

RA:

Hello Mr./Ms. [insert patient’s name]. My name is [insert your name], and I am a research assistant from the Johns Hopkins Hospital Emergency Department. I am calling to follow up on your visit to the emergency at Johns Hopkins three months ago on [insert date]. Is now a good time to talk? This will take less than 5 minutes.

Patient:

[Answers yes or no]

RA:

[If patient answers “yes,” then continue onto section B.]

[If patient answers “no,” then ask if there is a better time for you to call back.]

2. Follow-up Questions

1. When you visited the emergency room three months ago, you did not have insurance. Have been able to get insurance since your visit three months ago?

• Yes [Skip to question #3 if patient answers “yes.”]

• No

Patient’s comments: _________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

2. What has prevented you from getting insurance since your visit three months ago?

Patient’s answer: ____________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

3. Is there anything further that we can assist you with regarding either your insurance or your visit to the emergency room three months ago?

Patient’s answer: ____________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

3. Close

RA:

Thank you, Mr./Ms. [insert patient’s name] for taking the time to answer these questions. You have answered all of the follow-up questions that we had. Have a great day.

Public reporting burden for this collection of information is estimated to average 5 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.