Grantee Site Recruitment Materials

Attachment 4
Introductory and Recruitment Materials for Grantees, Sites, and Patients

RTI LEAD LETTER TO GRANTEES
DATE
DIRECTOR
ADDRESS
CITY, STATE ZIP
Dear [DIRECTOR],
On behalf of the Health Resources and Services Administration’s Bureau of Primary Health Care and RTI
International (RTI), we would like to request your participation in the Health Center Patient Survey. This
study aims to collect nationally representative data on patients who use health centers funded under
Section 330 of the Public Health Service Act. The results from the study will document the experience of
health center patients in 2013, and will be shared in aggregate form with other Federal government
agencies, Congress, national and state associations, health center program grantees, and the public.
Your organization is one of only 165 Health Center Program grantees selected to participate in this study.
We would like to involve some of your health center sites in the study, which will be conducted sometime
between August and December of 2014. Data collection activities will be scheduled at your convenience.
Your sites would be asked to allow RTI to conduct one-on-one personal interviews in a private location
with a sample of patients who received services in the previous year. Specifically, as patients arrive and
check in for services, your staff will be asked to direct a subset of them to the RTI interviewer. Since
interviews will be conducted by RTI, there will be minimal burden on your staff. On average, each
interview will take 75 minutes. The questionnaire is available for your review.
All information obtained during the study will be kept private and stored without personal identifiers and
will be used for research purposes only. We will work with you and the site staff to ensure that the data
collection activities adhere to the research requirements of your facilities. We also assure you and the site
staff that the findings from the study will not be used to assess the performance of the individual site or
grantee.
After the completion of study activities, your organization will receive a report summarizing the results
for your patients, with comparisons to results from all other participating grantees. This report will
provide objective information that can be shared with key stakeholders and used to inform the
organization about health care services received by its patients. All other study products will present
aggregate results only.
In the next week, NAME OF GRANTEE RECRUITER, a member of the RTI research team, will contact
you to discuss this request in more detail, to obtain site-related information necessary for conducting the
survey, and to answer any questions or concerns that you may have. If you prefer, you may contact
him/her by calling toll free (800)XXX-XXXX, extension _____. We recognize that participation may
present a variety of challenges, but our hope is that you will permit us to work with you and your site staff
to develop a plan that will effectively address any concerns and enable your participation.
Thank you in advance for your time and thoughtful consideration.
Sincerely,
Kathleen Considine
RTI International Project Director
Enclosures: BPHC Letter of Support and RTI Brochure

RTI LEAD LETTER TO SITES
DIRECTOR
ADDRESS
CITY, STATE ZIP
Dear [DIRECTOR],
On behalf of the Health Resources and Services Administration’s Bureau of Primary Health Care and RTI
International, we would like to request your participation in the Health Center Patient Survey. This study
aims to collect nationally representative data on patients who use health centers funded under Section 330
of the Public Health Service Act. The results from the study will document the experience of health center
patients in 2013, and will be shared in aggregate form with other Federal government agencies, Congress,
national and state associations, health center program grantees, and the public.
Your organization was one of 165 Health Center Program grantees selected for participation in this study,
and your site was selected within your organization. We have already spoken with your organization’s
administration, and received permission to contact you about this important study. The study will be
conducted sometime between August and December of 2014. Data collection activities will be scheduled
at your convenience. Your participation will involve allowing RTI to conduct one-on-one personal
interviews in a private location with a sample of patients who received services in the previous year.
Specifically, as patients arrive and check in for services, your staff will be asked to direct a subset of them
to the RTI interviewer. Since interviews will be conducted by RTI, there will be minimal burden on your
staff. On average, each interview will take 75 minutes. The questionnaire is available for your review.
All information obtained during the study will be kept private and stored without personal identifiers, and
will be used for research purposes only. We will work with you and your staff to ensure that the data
collection activities adhere to the research requirements of your facilities. We also assure you that the
findings from the study will not be used to assess the performance of the individual site or grantee.
After the completion of study activities, your grantee organization will receive a report summarizing the
results for the grantee’s patients, with comparisons to results from all other participating grantees. This
report will provide objective information that can be shared with key stakeholders and used to inform the
organization about health care services received by the grantee’s patients. All other study products will
present aggregate results only.
In the next week, NAME OF GRANTEE RECRUITER, a member of the RTI research team, will contact
you to discuss this request in more detail, to obtain site-related information necessary for conducting the
study, and to answer any questions or concerns that you may have. If you prefer, you may contact him/her
by calling toll free (800) XXX-XXXX, extension _____. We recognize that participation may present a
variety of challenges, but our hope is that you will permit us to work with you and your staff to develop a
plan that will effectively address any concerns and enable your participation.
Thank you in advance for your time and thoughtful consideration.
Sincerely,
Kathleen Considine
RTI International Project Director

Enclosures: BPHC Letter of Support and RTI Brochure

BPHC Lead Letter to Grantees and Sites

BPHC LEAD LETTER TO GRANTEES AND SITES

DATE
Dear Colleague:
The Health Resources and Services Administration’s Bureau of Primary Health Care is pleased to invite
you to participate in the 2014 Health Center Patient Survey. The Patient Survey aims to collect nationally
representative data on health center patients to document the effectiveness of the Health Center Program
in providing comprehensive primary and preventive health care. The 2014 survey has been revised from
previous surveys to more closely align with national surveys and to more narrowly focus on the most
critical aspects of a health center patient’s experience.
The Bureau of Primary Health Care invites your program to participate in this important survey that
will assist in improving the quality of the care provided across the Health Center Program. We have
contracted with RTI International, a non-profit research firm, to conduct the Patient Survey.
After the completion of survey activities, your grantee organization will receive a report summarizing
the results for the grantee’s patients, with comparisons to results from all other participating health
center grantees. This report will provide objective information that can be shared with key
stakeholders and used to inform your health center about health care services received by the
grantee’s patients. All other survey products will present aggregate results only.
The Health Center Patient Survey will be conducted with a select group of health centers that are
representative of the national Health Center Program. We encourage you to take advantage of this
opportunity to receive feedback on your patients’ experiences, and thank you in advance for your
commitment to improving the health of the Nation’s underserved communities and vulnerable
populations.
For more detailed information on this study, please read the enclosed materials from RTI International or
feel free to contact XXXXX at [email protected] or (xxx) xxx-xxxx.

Sincerely,

Xxxxxxx
Xxxxxxxxxxxx

INFORMATION TO BE INCLUDED AS PART OF A TRIFOLD
BROCHURE (DESIGN IS IN PROGRESS)
Frequently Asked Questions About the
Health Center Patient Survey
What is the survey about? What is the purpose?
RTI (Research Triangle Institute) International is conducting the Health Center Patient Survey. The
survey is sponsored by the Bureau of Primary Health Care within the Health Resources and Services
Administration (HRSA). This survey is about people who receive health care at health centers like this
one. The survey will try to find out what kinds of health issues people who use the health centers have
and how well their needs are met. The survey is not associated with any immigration laws and the agency
sponsoring the study is not associated with an immigration agency.

What is involved and how long will it take?
If you agree to participate, you will take part in an in person interview conducted by one of our
interviewers. We will conduct the interview in private at the health center or another convenient location.
All responses will be kept private. You may refuse to answer any question and you may also stop the
interview at any time.

What types of questions will be asked?
Questions about health care received, medical conditions, alcohol and drug use and health insurance will
be asked.

How long are the interviews?
The time varies, but interviews generally take 75 minutes.

Will I be paid?
You will receive $25 cash or a gift of equal value for your participation. The form of payment has been
selected by this health center.

What about my privacy?
The information you provide will be private. We will create and use a number instead of your name to
identify your interview in the computer. This will prevent anyone from finding out what your answers
were. After you complete the interview, the interviewer will not be able to look at your answers again.
We will combine your information with information from all of the other participants to create group
statistics.

Why was I selected for this study?
RTI requested the cooperation of about 495 health centers to conduct this study. This health center has
agreed to participate. You have been randomly selected from this health centers’ patients to participate.

Why should I participate?
Your opinions and experiences are valuable. You represent thousands of others who receive similar care
and services. Information we gather through these surveys will provide policy makers and health centers
with a better understanding of how patients are being served and how to better serve patients at these
health centers.

Do I have to participate?
You do not have to participate in this survey or respond to any questions you do not want to answer. If
you choose not to participate it will not affect any services you or your family may receive at the health
center or any other programs.

What is the RTI International?
RTI International is a nonprofit company in Research Triangle Park, North Carolina. RTI conducts
research and provides services to local, state, and federal agencies.

I have more questions. Who can answer them?
If you have any questions about these studies, you may call Kathleen Considine at (800) 334-8571
Ext. 26612 or Azot Derecho at (800) 334-8571 Ext. 27231. If you have any questions about
your rights as a study participant, you may call RTI’s Office of Research Protections toll-free
at (1-866-214-2043).

Grantee
Recruitment Guidelines

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GRANTEE RECRUITMENT GUIDELINES
SUGGESTED INTRODUCTION SCRIPT:
[ASK FOR CONTACT PERSON IDENTIFIED IN VERIFICATION CALL]
Hello, my name is ________________ and I’m calling on behalf of HRSA and the Bureau of
Primary Health Care about the Health Center Patient Surveys. I’m calling from Research
Triangle Institute International, which has been contracted to conduct the patient survey. I was
given your name as the person in your office that is the most knowledgeable about the health
center sites that your organization funds via Section 330 funding. I recently mailed study
information to you. I am calling today to discuss the survey in more detail and answer any
questions that you may have regarding participation. Do you have time to talk with me now?
[THE FIRST CALL MAY LAST 10 MINUTES]. [IF NO]…I will be happy to call back at a time that
is more convenient for you. [SET UP APPOINTMENT DATE AND TIME]

THE FOLLOWING MUST BE DISCUSSED DURING THE INITIAL OR SUBSEQUENT CALLS:
1.

Give summary of the patient surveys. Include purpose and major tasks.
The purpose of this survey is to obtain nationally representative data about the health
and health care needs of patients who received services at Section 330 funded health
centers. The national study will provide policy makers and service providers with a better
understanding of the health problems and needs of these patients, their health care
utilization, and met and unmet needs.

2.

Clarify our request.
We are seeking permission from the grantees to collect data at a sample of their sites.
We are requesting information on their sites so that our statistician can select the
sample of sites. Each selected site will be asked to allow RTI to conduct one-on-one
private, personal interviews with patients who have used the site in the previous year
(approx XX interviews per grantee, X or X per site). Copies of the interview questions
are available for grantee review.

3.

Identify any perceived barriers to participation and work out plans to alleviate such
barriers.

4.

Discuss the approval process that is required at the Grantee level. Do they have an
IRB that will need to review this? If so, when is its next meeting? Do they have any other
Board that will need to review this? If so, when is its next meeting? Offer assistance in
obtaining study approval and/or gaining their cooperation. RTI must receive written
notification of approval, if applicable. Discuss and document local requirements for
obtaining informed consent from minors and proxies.

5.

Address concerns about patient protection. Protective measures for the patient
surveys include:
• informing respondents up front that some of the questions may be sensitive in nature
and that they have the right to refuse to answer any questions;

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•
•
•
•
•
•

reassuring all respondents that they are under no obligation to respond to the
interview and may terminate their participation at any time;
informing respondents that their answers are private, and that their names will not be
associated with responses provided;
conducting the interviews in a private location;
reporting information obtained from the interviews only in summary form;
maintaining hard copies of the consent forms in a locked storage cabinet;
destroying hard copies of consent forms after they are no longer needed.

Obtain the following information for each eligible site associated with the Grantee. Eligible
sites are defined as follows :
• The site should participate in at least one of the four funding programs and must have been
operating under the grantee for at least 1 year.
•

The site is not a school-based health center.

•

The site is not a specialized clinic, excepting clinics providing OB/GYN services.

•

The site does not provide services only through migrant and seasonal farmworker voucher
screening program.

Name of site__________________________________
Contact Information
Name_________________________________
Title___________________________________
Address________________________________
Phone_________________________________
Email__________________________________
Fax___________________________________
Percent of users by race during 2013: (CIRCLE YES OR NO)
At least 20% of Patients are Asians Yes / No
At least 20% of Patients are American Indians/Alaskan Natives (AIAN) Yes / No
At least 20% of Patients are Native Hawaiian/Pacific Islanders (NHPI) Yes / No
Populations served (Circle Yes or No)
Migrant or seasonal farmworkers
Yes / No
Homeless
Yes / No
Public Housing
Yes / No
Other (Community health)
Yes / No
Number or Percent of users by population type during 2013:
Migrant or seasonal farmworkers
Homeless
Public Housing
Other (Community Health)
______Total

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Type of site (select one for Homeless Site only)
Fixed serving homeless and general population
Fixed serving homeless only
Mobile serving homeless and general population
Mobile serving homeless only
Eligibility
Number of years in operation (allow decimal points)
Receives at least partial section 330 funding (yes/no)
Types of services
Conducts intake (yes/no)
Face-to-face contact with clients (yes/no)
Language
___% Patients speaking Spanish only
___% Patients speaking Mandarin only
___% Patients speaking Cantonese only
___% Patients speaking Korean only
___% Patients speaking Vietnamese only
___% Patients speaking other language; SPECIFY LANGUAGE_____________
6.

After grantee agrees to participate, ask this contact for suggested sequence for other
approvals/permissions. Specifically, are there approvals that must be acquired before
contacting the site or can we immediately make contact with the site?

7.

Discuss Letter of Agreement, if applicable.

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Site Recruitment Guidelines
EXAMPLE SCRIPT OF INTRODUCTION:
[ASK FOR PERSON THAT SHOULD HAVE RECEIVED THE ADVANCE PACKAGE]
Hello, my name is ________________ and I’m calling on behalf of the HRSA and the Bureau of
Primary Health Care about the Health Center Patient Survey which is sponsored by the Bureau
of Primary Health Care within the Health Resources and Services Administration (HRSA). I’m
calling from RTI International, which has been contracted to conduct the patient survey. I have
already spoken with [GIVE NAME OF CONTACT AT THE GRANTEE ORGANIZATION] and
he/she has given me permission to contact you about the survey. I sent you some materials in
the mail about the survey. I am calling today to discuss the survey in more detail and answer
any questions that you may have regarding participation.
Do you have time to talk with me now? [THE FIRST CALL MAY LAST 10 MINUTES]. [IF NO]…I
will be happy to call back at a time that is more convenient for you. [SET UP APPOITMENT
DATE AND TIME]
Have you had a chance to look over those materials? [IF NO]…. I will be happy to call back after
you’ve had a chance to do so. [SET UP APPOINTMENT DATE AND TIME]

THE FOLLOWING MUST BE DISCUSSED DURING THIS CALL OR DURING
SUBSEQUENT CALLS:
Give summary of the patient surveys. Include purpose and major tasks.
The purpose of this survey is to obtain nationally representative data about the health
and health care needs of patients who received services at Section 330 funded health
centers. These national survey will provide policy makers and service providers with a
better understanding of the health problems and needs of these patients, their health
care utilization, and met and unmet needs.
Verify information obtained from grantee concerning contact information, users by race, %
requiring a translator, type of site and eligibility criteria.
Clarify our request.
Each selected site will be asked to allow RTI to conduct one-on-one private, personal
interviews with people who have used the site in the previous year (approx XX
interviews per grantee, X or X per site). Copies of the interview questions are available
for grantee review.
Discuss the schedule for data collection: August - December 2014. We will schedule the data
collection at their convenience, but it must be conducted within this time frame. Let site
know that an RTI interviewer will be conducting the interviews.
What are the days and hours of operation?

Assist in developing the site-specific protocol for reporting situations of distress/abuse or
harm to participants or others. Also, develop referral protocol for respondents
requesting services or assistance. Obtain the name of an appropriate person at the
site or grantee organization for referrals, if applicable and appropriate.
Address concerns of patient protection. Protective measures for the patient surveys include:
• informing respondents up front that some of the questions may be sensitive in nature
and that they have the right to refuse to answer any questions;
• reassuring all respondents that they are under no obligation to respond to the interview
and may terminate their participation at any time;
• informing respondents that their answers are private, and that their names will not be
associated with responses provided;
• conducting the interviews in a private location;
• reporting information obtained from the interviews only in summary form;
• maintaining hard copies of the consent forms in a locked storage cabinet;
• destroying hard copies of consent forms after they are no longer needed;
Discuss study logistics.
Number of patients per day:
Migrant and seasonal farmworkers (if any)
Homeless (if any)
Public Housing (if any)
All other (Community Health)
Best time to interview patients (select one)
While awaiting receipt of services
After receiving services
Special appointment
Interviewing Space
Specify arrangement
Is space available for more than one interviewer at a time? Yes/No
Preference for respondent incentive (Mark all that apply)
Cash
Visa gift card
Food voucher
Other (Specify)
Discuss the Letter of Agreement, if applicable.

LETTER OF AGREEMENT FOR A PARTICIPATING SITE

Dear
This letter will serve as an agreement between you and RTI International regarding your facility’s
participation in the Health Center Patient Survey. As you know, the Patient Survey, sponsored by the
Bureau for Primary Health Care within the Health Resources and Services Administration (HRSA) is
being conducted by RTI, a not-for-profit organization based in North Carolina.
The purpose of the survey is to collect data on patients who use health centers funded under
Section 330 of the Public Health Service Act, to support the Bureau’s mission to improve the health of the
nation’s medically underserved communities and populations, and to ensure access to high-quality
primary health care services.
Please review the following information for accuracy:
1. Your site’s administration has agreed to allow the facility to participate. The specific elements of
participation were outlined in the patient surveys overview that you received previously. The
surveys involve in-person interviews with patients aged 13 and older and in-person interviews
with the parents/guardians of patients who are under age 12. (For all interviews conducted with
13-17 year olds, parental consent and minor assent will be obtained.) All data collected will be
strictly private and will be used for research purposes only.
2. Your internal review process is complete and the research is approved for implementation at your
site. No exceptions or stipulations were noted.
3. The designated contact person from your site is .
4. Your staff and RTI have determined the protocol for addressing subjects that may display
significant emotional distress or volunteer other information that requires intervention or
reporting.
5. Data collection for the visit survey will be conducted between [MONTH] and [MONTH] 2014.

Your signature below indicates that you confirm/agree with the contents of this letter and that the
Health Center Patient Survey can be initiated at your site.

_____________________________ ___________________
Date

Please make a copy of this letter for your records. Please fax this signed letter to [RECRUITER]
at 919 XXX-XXXX). After faxing the letter, please return the original to RTI in the enclosed selfaddressed stamped envelope.
If you have any questions now, or at any time during the study, please do not hesitate to call Kathleen
Considine at 1-800-XXX-XXXX, ext XXXX. We look forward to working with you and your staff.
Again, thank you for participating in this study.

Sincerely,

Kathleen Considine
RTI Project Director

Health Center Patient Survey
Respondent Recruitment Script

You have been invited to participate in an interview as part of an important research effort
being conducted by RTI International and sponsored by the Bureau of Primary Health Care.
The interview asks about your health care experiences and some other topics.
If you are eligible to complete the survey, you will receive $25 in cash or a gift of equal
value as thanks for your participation.
Here is a brochure that provides information about the study.
If you are interested in participating, or have any questions, please read the brochure and
speak with the on-site RTI representative, _______________________________.
If the on-site RTI representative is not available and you would like to find out more
information about the study, I can set an appointment for you to speak with her/him.
We hope you will choose to participate.
Thank you!

Health Center Patient Survey
Interviewer Recruitment Script
INTRODUCTION
Hello my name is: YOUR NAME and I work for RTI International, a not-for-profit research firm located
in Raleigh/Durham North Carolina.
I am here at: NAME OF CLINIC to conduct a patient survey sponsored by the Bureau of Primary Health
Care within the Health Resources and Services Administration.
The survey will try to find out what kinds of health problems people come to health centers with and how
well the health centers are meeting the needs of the people who use them.
The face-to-face survey will take approximately 75 minutes and we will provide $25 as a token of
appreciation for participating. The survey is voluntary and all information that you tell me will be kept
completely confidential.
I would first like to ask you a few questions to determine whether you are eligible to participate.
IF NOT IN PRIVATE LOCATION: If you will follow me, we can go to a private location to ask you the
eligibility questions.

CONTACT SUMMARY REPORT FORM

2014 Health Center Patient Survey
Contact Summary Report Form
Case ID:___________________________
FI Name:__________________________

FS Name:______________________________

Grantee Number:____________________

Grantee Name:__________________________

Site Number:_______________________

Site Name:_____________________________

RECORD OF CONTACTS

DATE

TIME

TYPE OF
INTERVIEW

STATUS*

COMMENTS

* IF AN APPOINTMENT IS SET FOR A LATER TIME, DOCUMENT THE RESPONDENT’S FIRST NAME,
CONTACT NUMBER, THE LOCATION AND TIME OF THE APPOINTMENT, AND THE PARENT/GUARDIAN NAME
(IF APPLICABLE) IN THE COMMENTS SECTION.

Interviewer Notes:

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Status Codes: (To be finalized and inserted)

Patient Screening Form
Primary Health Care Patient Survey

FRONT END:
PROGRAMMER: WE WILL NEED TO DEVELOP THE FOLLOWING VARIABLES FROM
INORMATION GATHERED AT GRANTEE RECRUITMENT:
DEVELOP VARIABLE “FAC1”=NAME OF FACILITY [ALLOW 40]
DEVELOP VARIABLE “STATE” [ALLOW 2 CHARACTER STATE ABBREVIATION]
PROGRAMMER: DO NOT ALLOW DK OR REF RESPONSE FOR ANY OF THE SCREENER
QUESTIONS.

S_LANG.
SELECT 1 FOR ENGLISH
SELECT 2 FOR SPANISH
SELECT 3 FOR CHINESE - MANDARIN
SELECT 4 FOR CHINESE - CANTONESE
SELECT 5 FOR KOREAN
SELECT 6FOR VIETNAMESE
[NOTE TO PROGRAMMER: WE WILL BE USING THE SAME CHINESE INSTRUMENT
FOR BOTH MANDARIN AND CHINESE. WE JUST NEED A MECHANISM IN THE
SCREENER TO KEEP TRACK OF THE DIFFERENT TYPES OF INTERVIEWS.]
S1a.

IS THIS A PROXY INTERVIEW?
1=YES [USE TO DEVELOP PROPER FILLS] -- CONTINUE
2=NO – GOTO S3

S1_child

What is your child’s first name? I just need a way of referring to your child.
[Allow 20]

S3. Please tell me the age category that applies to {you/name}?
PROBE FOR BEST ESTIMATE, IF NECESSARY
IF UNABLE TO COMPLETE SCREENING, ENTER YOUR BEST GUESS BASED ON
OBSERVATION
1=12 and under
2=13 to 17
3=18 to 34
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4=35 to 49
5=50 to 64
6=65 and older
[IF NOT A PROXY INTERVIEW AND IF S3=1, PRESENT ERROR MESSAGE:
“Children 12 years old and younger should only be interviewed through a proxy.”]
RETURN TO S1a.
S_INT1.
The first few questions are for statistical purposes only, to help us analyze the results of the
study.
Do you consider {yourself/name} to be Hispanic or Latino(a)?
1=YES
2=NO
S_INT2.
What race or races do you consider {yourself/name} to be? You may select all that apply.
{FILL: Are you/Is he/Is she}...
EXPLAIN, IF NECESSARY: “We ask this for statistical purposes only, to help us analyze the
results of the study.”
NOTE: CODE “NATIVE AMERICAN” AS “AMERICAN INDIAN”
IF UNABLE TO COMPLETE SCREENING, ENTER YOUR BEST GUESS BASED ON
OBSERVATION
1=White
2=Black or African American
3=American Indian or Alaska Native (American Indian includes North American, Central
American, and South American Indians)
4=Native Hawaiian
5=Guamanian or Chamorro
6=Samoan
7=Tongan
8=Marshallese
9=Asian Indian
10=Chinese
11=Filipino
12=Japanese
13=Korean
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14=Vietnamese
15=Other
S_INT3.
IF SELF-RESPONDENT: RECORD; IF NOT OBVIOUS, ASK: What is your gender?
IF PROXY-RESPONDENT, ASK: What is {name’s} gender?
[SHOW ONLY FOR RESPONDENTS GE 13 YEARS OLD, NON PROXY
INTERVIEWS:] IF R ANSWERS THAT THEYARE TRANSGENDER AND WHICH
KIND IS NOT OBVIOUS – PROBE IF THEY ALTERED GENDER FROM MALE TO
FEMALE OR FROM FEMALE TO MALE
IF UNABLE TO COMPLETE SCREENING, ENTER YOUR BEST GUESS BASED ON
OBSERVATION
EXPLAIN, IF NECESSARY: “We ask this for statistical purposes only, to help us analyze the
results of the study.”
1=MALE
2=FEMALE
3=OTHER
S1b.

Thank you for your interest in participating in this patient survey. I have a few questions
to determine whether or not {you are /name is} eligible.

{Have you}{Has your child} received services from a health care professional such as a doctor,
nurse, drug counselor, mental health counselor, or dentist at {reference health center} in the last
12 months, that is since {12 MONTH REFERENCE DATE}?
1=YES
2=NO --- [GOTO END1 AND SET EVENT CODE TO 1320.]

S2_Intro
S2a.

Do any of the following apply to you?

Have you worked as a farmworker in the past 24 months or have you or has anyone in
your family been supported by someone who worked as a farmworker in the past 24
months?
1=YES
2=NO

S2b.

In the past 12 months, has there been a period in which you have been without regular
housing or homeless? To clarify, that is not living in your own house, apartment, or
room on a regular basis and not in a hospital or jail/prison. For example, living in a

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shelter, on the street/campsite/car/etc. or in temporary or transitional housing where
services are provided.
1=YES
2=NO
S2c.

Are you currently living in a public housing unit? Do not count Section 8 housing as
public housing.
IF NEEDED, YOU MAY EXPLAIN: “Public housing is housing that is built, operated, and
owned by a government and that is typically provided at nominal rent to the needy.”

1=YES
2=NO
S4_Intro.

INTERVIEWER: PLEASE ANSWER THE FOLLOWING QUESTIONS

S4a.

HAS YOUR QUOTA BEEN MET FOR FARMWORKERS
1=YES
2=NO
3=NO QUOTA FOR THIS FUNDING TYPE

S4b.

HAS YOUR QUOTA BEEN MET FOR HOMELESS
1=YES
2=NO
3=NO QUOTA FOR THIS FUNDING TYPE

S4c.

HAS YOUR QUOTA BEEN MET FOR PUBLIC HOUSING
1=YES
2=NO
3=NO QUOTA FOR THIS FUNDING TYPE

S4d.

HAS YOUR QUOTA BEEN MET FOR CHC
1=YES
2=NO
3=NO QUOTA FOR THIS FUNDING TYPE

NOTE TO PROGRAMMERS: THE FOLLOWING PRELOAD WILL COME FROM
SAMPLING AS THEY DETERMINE WHAT FUNDING TYPE THIS SITE FALLS
UNDER.
IF SITE = SINGLE FUNDING TYPE [FARMWORKER] THEN DEVELOP NEW
VARIABLE “FARM0” AND GO TO S5, ELSE CONTINUE
IF SITE = SINGLE FUNDING TYPE [HOMELESS] THEN DEVELOP NEW VARIABLE
“HOME0” AND GO TO S5, ELSE CONTINUE

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IF SITE = SINGLE FUNDING TYPE [PUBLIC HOUSING] THEN DEVELOP NEW
VARIABLE “PUB0” AND GO TO S5, ELSE CONTINUE
IF SITE = SINGLE FUNDING TYPE [CHC] THEN DEVELOP NEW VARIABLE “CHC0”
AND GO TO S5, ELSE CONTINUE TO S4e.
S4e. SELECTION:
IF S2a=1 AND S4a=2 THEN CREATE NEW VARIABLE FARM1=1, ELSE FARM1=2
IF S2b=1 AND S4b=2 THEN CREATE NEW VARIABLE HOME1=1, ELSE HOME1=2
IF S2c=1 AND S4c=2 THEN CREATE NEW VARIABLE PUB1=1, ELSE PUB1=2
IF S4d=2 AND S2a = 2 AND S2b = 2 AND S2c = 2 THEN CREATE NEW VARIABLE
CHC1=1, ELSE CHC1=2
IF S4A-S4D ALL EQUAL 1, THEN FILL: “ALL OF YOUR QUOTAS ARE FILLED.
PLEASE DO NOT CONTINUE TO INTERVIEW AT THIS SITE.” SET EVENT
CODE TO 1390
IF FARM1=2 and HOME1 = 2 and PUB1 = 2 and CHC1=2 THEN CREATE NEW VARIABLE
CALLED PTYPE AND SET PTYPE TO EQUAL 5. SKIP TO END1.
IF FARM1=1 AND HOME1=2 AND PUB1=2 AND CHC=2, THEN SET PTYPE = 2 AND
FILL: “You have been selected for an interview. Would you be able to complete the
interview at this time? IF YES – PROCEED WITH INTERVIEW. IF NO – BREAKOFF
AND SCHEDULE A TIME TO INTERVIEW IN CMS. RESPONDENT INTERVIEW
SELECTED AS @UFARMWORKER@U – PLEASE UPDATE QUOTA AND CSR IF
R AGREES TO PARTICIPATE AND CONTINUE WITH INTERVIEW.
IF HOME1=1 AND FARM1=2 AND PUB1=2 AND CHC=2 THEN SET PTYPE = 3 AND
FILL: “You have been selected for an interview. Would you be able to complete the
interview at this time? IF YES – PROCEED WITH INTERVIEW. IF NO – BREAKOFF
AND SCHEDULE A TIME TO INTERVIEW IN CMS. RESPONDENT INTERVIEW
SELECTED AS @UHOMELESS@U – PLEASE UPDATE QUOTA AND CSR IF R
AGREES TO PARTICIPATE AND CONTINUE WITH INTERVIEW”
IF PUB1=1 AND HOME1=2 AND FARM1=2 AND CHC=2 THEN SET PTYPE = 1 AND
FILL: “You have been selected for an interview. Would you be able to complete the
interview at this time? IF YES – PROCEED WITH INTERVIEW. IF NO – BREAKOFF
AND SCHEDULE A TIME TO INTERVIEW IN CMS. RESPONDENT INTERVIEW
SELECTED AS @U PUBLIC HOUSING@U – PLEASE UPDATE QUOTA AND CSR
IF R AGREES TO PARTICIPATE AND CONTINUE WITH INTERVIEW”
IF CHC1=1 AND S2b=2 AND S2c=2 AND S2a=2 THEN SET PTYPE = 4 AND FILL: “You
have been selected for an interview. Would you be able to complete the interview at this
time? IF YES – PROCEED WITH INTERVIEW. IF NO – BREAKOFF AND
SCHEDULE A TIME TO INTERVIEW IN CMS. RESPONDENT INTERVIEW

5

SELECTED AS @UCHC@U – PLEASE UPDATE QUOTA AND CSR IF R AGREES
TO PARTICIPATE AND CONTINUE WITH INTERVIEW”
MULTIPLE SELECTION:
IF 2 OR MORE OF THE FOLLOWING: FARM1=1 AND/OR HOME1=1 AND/OR PUB1=1
AND/OR CHC1=1 THEN CONTINUE ELSE GOTO END1
SELECTION OF VARIABLES WHEN 2 OR MORE OF THE FOLLOWING (FARM1,
HOME1, PUB1) = 1.
IF PUB1=1 THEN SET PTYPE = 1 AND FILL “You have been selected for an interview.
Would you be able to complete the interview at this time? IF YES –PROCEED WITH
INTERVIEW. IF NO – BREAKOFF AND SCHEDULE A TIME TO INTERVIEW IN
CMS.
RESPONDENT INTERVIEW HAS BEEN SELECTED AS [FILL: @UPUBLIC
HOUSING@U]”,
ELSE IF FARM1=1 THEN SET PTYPE = 2 AND FILL “You have been selected for an
interview. Would you be able to complete the interview at this time? IF YES –
PROCEED WITH INTERVIEW. IF NO – BREAKOFF AND SCHEDULE A TIME TO
INTERVIEW IN CMS.
RESPONDENT INTERVIEW HAS BEEN SELECTED AS [FILL:
@UMIGRANT@U]”,
ELSE IF HOME1=1 THEN SET PTYPE = 3 AND FILL “You have been selected for an
interview. Would you be able to complete the interview at this time? IF YES –
PROCEED WITH INTERVIEW. IF NO – BREAKOFF AND SCHEDULE A TIME TO
INTERVIEW IN CMS.
RESPONDENT INTERVIEW HAS BEEN SELECTED AS [FILL:
@UHOMELESS@U]”,
ELSE IF CHC1=1 THEN SET PTYPE = 4 AND FILL “You have been selected for an
interview. Would you be able to complete the interview at this time? IF YES –
PROCEED WITH INTERVIEW. IF NO – BREAKOFF AND SCHEDULE A TIME TO
INTERVIEW IN CMS.
RESPONDENT INTERVIEW HAS BEEN SELECTED AS [FILL: @UCHC@U]”,
“PLEASE UPDATE QUOTA AND CSR IF R AGREES TO PARTICIPATE AND
CONTINUE WITH INTERVIEW”

6

S4f.
IF FARM0: “You have been selected for an interview. Would you be able to complete the
interview at this time? IF YES – PROCEED WITH INTERVIEW. IF NO – BREAKOFF
AND SCHEDULE A TIME TO INTERVIEW IN CMS. RESPONDENT INTERVIEW
SELECTED AS @UFARMWORKER@U – PLEASE UPDATE QUOTA AND CSR IF
R AGREES TO PARTICIPATE AND CONTINUE TO S5.”;
IF HOME0: “You have been selected for an interview. Would you be able to complete the
interview at this time? IF YES – PROCEED WITH INTERVIEW. IF NO – BREAKOFF
AND SCHEDULE A TIME TO INTERVIEW IN CMS. RESPONDENT INTERVIEW
SELECTED AS @UHOMELESS@U – PLEASE UPDATE QUOTA AND CSR IF R
AGREES TO PARTICIPATE AND CONTINUE TO S5”;
IF PUB0: “You have been selected for an interview. Would you be able to complete the
interview at this time? IF YES – PROCEED WITH INTERVIEW. IF NO – BREAKOFF
AND SCHEDULE A TIME TO INTERVIEW IN CMS. RESPONDENT INTERVIEW
SELECTED AS @UPUBLIC HOUSING@U – PLEASE UPDATE QUOTA AND CSR
IF R AGREES TO PARTICIPATE AND CONTINUE TO S5”;
IF CHC0: “You have been selected for an interview. Would you be able to complete the
interview at this time? IF YES – PROCEED WITH INTERVIEW. IF NO – BREAKOFF
AND SCHEDULE A TIME TO INTERVIEW IN CMS. RESPONDENT INTERVIEW
SELECTED AS @UCHC@U – PLEASE UPDATE QUOTA AND CSR IF R AGREES
TO PARTICIPATE AND CONTINUE TO S5”;

S5. IF S3 = 13, 14, 15, 16, OR 17 CONTINUE
IF S3 = LE 12 = GOTO INTRO1, ELSE GO TO INTRO2
Is a parent or guardian with you?
1=YES
2=NO
[IF S5=1 GOTO INTRO3, ELSE SET EVENT CODE=2231 UNACCOMPANIED MINOR
AND GO TO END2]
END1

Thank you very much, but unfortunately you were not selected for interview.

END2

Thank you very much, but unfortunately we need to speak with your parent or
guardian to gain their permission for you to continue with the interview.

7

HEALTH CENTER STAFF TALLY SHEET
Please keep track of the number of patients who enter the site and the number of patients selected while the field interviewer is at the
site to conduct data collection.
You may either use tally marks to count patients as they enter or complete this table based on the sign-in sheet or appointment list
before the interviewer leaves this health center.

Age

65+

Race

Visited

Eligible

Referred

Approached
FI

Selected

Completed

(To be
completed by
Field
Interviewer)

(To be
completed by
Field
Interviewer)

(To be
completed by
Field
Interviewer)

All Race/
Ethnicity

American
Indian/Alaskan
Native
Native
Hawaiian/Pacific
Under 65 Islander
Asian
Other

VISITED = Total number of patients that arrive while field interview is on site.
ELIGIBLE = Patients that met the criteria described by the field interviewer.
REFERRED= Patients provided information about the interview and sent over to the field interviewer.