CHC Induction Survey

Attachment C5: 2015 NAMCS-201 CHC Service Delivery Site Induction Interview, List of all questions

This table lists all proposed 2015 survey questions in the order that they would appear in the survey. Additions and modifications for 2015 are highlighted in yellow. Instructions for field representatives are in blue.

OMB No. 0920-0234 Exp. Date XX/XX/20XX

Notice-Public reporting burden for this collection of information is estimated to average 20 minutes per response, including 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 current valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing burden to:  CDC/ATSDR Information Collection Review Office, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN:  PRA (0920-0234).

Assurance of confidentiality-All information which would permit identification of an individual, a practice, or an establishment will be held confidential; will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls; and will not be disclosed or released to other persons without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).

Variable name	Question text and answer categories
START	One button is selected to start the interview: 1. Continue 2. Noninterview (Unable to locate, refusal, etc.) 3. Issue preventing CHC facility interview 4. Quit
CHCTYPE	How would you classify this center? Enter all that apply - separate with commas Federally-funded Community Health Center (330) Community Health Center (CHC) Migrant Health Center (MHC) Health Care for the Homeless (HCH) Public Housing Primary Care (PHPC) grant program Federally Qualified Health Center, but not federally funded (330 look-alike) Urban Indian (437) Health Center None of the above
ADDCHECK	We have your address and telephone number as (Name and Address) (Phone number) Is this correct? Yes No, update address and phone
CHC_NAME	What is the correct address?         Enter 1 to update the CHC name, address, and phone
PR330 PRTITLEV PROTHFED PRSTLOC PRPRIVAT PRCARE PRCAID PRFEES PROTHER TOTALGRANT	What percent of your CHC's revenue comes from the following sources? 330 Grant Title V grant or contract Other Federal Grant State/Local Grant Individual, corporation or foundation grants or donations Medicare Medicaid/CHIP Patient payments Other (including private insurance, Tricare, VA, etc.)?
AVG_WEEKS	On average, in a normal year, how many weeks does the CHC at this location see patients?" ________Number of weeks
WEEK_FOLLUP	"You indicated that this CHC LOCATION does not usually see patients in a typical year, is this correct?" Yes No
INTRO_SAMP	I would like to discuss a plan for conducting the National Ambulatory Medical Care Survey (NAMCS) to a sample of your providers.  This center has been assigned to a 1-week reporting period that begins on Monday, (Reporting period start date) and ends on Sunday, (Reporting period end date). I will need to sample 3 providers from your Center.  In order to do this, I will need the name, specialty, and estimated visit volume, corresponding to the sample week, for all physicians and mid-level providers ONLY AT THE CURRENTLY SAMPLED IN-SCOPE LOCATION.  Please include all providers even if they do NOT plan on seeing patients during the sample week.  In-scope locations include all fixed locations that provide health care, including mobile clinics, and specialty clinics.  Please do not include providers that work solely at school-based clinics. Please exclude anesthesiologists, dentists, hygienists, optometrists, pathologists, psychologists, podiatrists, and radiologists.  Include physicians (both MDs and DOs), nurse practitioners (NPs), physician assistants (PAs), and nurse midwives (NMWs).   List all providers only from the currently sampled in-scope locations, even if they do not expect to see patients during the sampled week.  Enter a zero for the expected visit volume for those providers with no expected visits.        If the CHC that has been sampled is a health department, please verify that they will not be distributing the 330 grant money to other administratively unconnected community health centers.  If the health department  does distribute the money to other CHCs, these need to be sampled, so please contact your supervisor for further instructions.
PROV_FNAME	What is the provider's first name? (Include providers from all in-scope CHC locations.)
PROV_MNAME	What is the provider's middle name?
PROV_LNAME	What is the provider's last name?
PROV_TYPE	Is (Provider's name) a Medical Doctor (MD) or Doctor of Osteopathy (DO), Nurse Practitioner (NP), Physician Assistant (PA), or Nurse Midwife (NMW)? Medical Doctor (MD) Doctor of Osteopathy (DO) Nurse Practitioner (NP) Physician Assistant (PA) Nurse Midwife (NMW)
Skip Instructions:	1,2: Goto PROV_SPEC Else goto PROVIDED
PROV_SPEC	What is (Provider's name)'s specialty?   Enter 'XXX' if the specialty is not listed
PROV_SPEC2	Is the provider an anesthesiologist, dentist, hygienist, optometrist, pathologist, psychologist, podiatrist, or radiologist? Yes No
PROV_SPEC_SP	Enter verbatim response for specialty
PROVIDED	?  [F1] What is the expected visit volume during the sample week for (Provider's name)?          Enter 0 if provider does not expect to see patients during the reference period.
PREVSAMP	Compare this provider ((Providers name)) to the listed providers that have been sampled from this community health center in the past.           Previously sampled providers         (Previously sampled providers) Yes, previously sampled No, not previously sampled
VER_PREVSAMP	Were the previously sampled providers selected correctly?            Current name                     Previous name          (Current provider names)     (Previously sampled provider names) Yes No
NOPATIENTS	You have told me that NONE of these providers expect to see patients during the sample week that begins on Monday, (Reporting period start date) and ends on Sunday, (Reporting period end date).  Is this correct? Yes, there are no providers seeing patients during reference week No, incorrect - there are providers seeing patients
Skip Instructions:	1: Exit block and goto BlkBACK.THANK_OOS 2: Go back to TblProv1.PROV_FNAME for the last row.
PROV_STRT	What is (Provider's name)'s address?            Enter number and street.
PROV_STRT2	What is (Provider's name)'s address?            Enter line two of address.
PROV_CITY	What is (Provider's name)'s address?           Enter city.
PROV_STATE	What is (Provider's name)'s address?           Enter state.
PROV_ZIPCODE	What is (Provider's name)'s address?          Enter zipcode.
PROV_LOCTYPE	Enter location/address type Main Office address Alternative/2nd office address Home office Home Unknown
PROV_PHONE	What is (Provider's name)'s telephone number?
PROV_PHTYP	What type of telephone number is this? Main Home Work Mobile Pager, Beeper, Answering Service Public pay phone Toll Free Other Fax Unknown
GREET_NAME	Enter Greet Name    (Greet name will be used on the letter that is sent to the provider.)     Provider Name:  (Provider's name)
CALLBACKNOTES	I'd like to schedule a DATE to (conduct/complete) the interview. What DATE AND TIME would be best to visit again?            Today is:  ^IntDate
Skip Instructions:	RF: Goto CBREF All others, goto THANKCB
CBREF	Exit this case now.     Call the case up again and make it a non-interview before transmitting.
THANKCB	Thank you. I will call/come back at the time suggested       Revisit   (Appointment information)
THANKYOU	This concludes the interview.  Thank you for your patience, and for taking the time to answer our questions.
THANK_OOS	Thank you (Respondent name), your center is not within the scope of this study. We appreciate your time and interest.

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