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?
|
ADDCHECK |
We
have your address and telephone number as
|
CHC_NAME |
What
is the correct address? |
PR330 PRTITLEV PROTHFED PRSTLOC PRPRIVAT PRCARE PRCAID PRFEES PROTHER TOTALGRANT |
What percent of your CHC's revenue comes from the following sources?
|
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?"
|
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). |
PROV_FNAME |
What
is the provider's first name? |
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)?
|
Skip Instructions: |
1,2: Goto PROV_SPEC |
PROV_SPEC |
What
is (Provider's name)'s specialty? |
PROV_SPEC2 |
Is the provider an anesthesiologist, dentist, hygienist, optometrist, pathologist, psychologist, podiatrist, or radiologist?
|
PROV_SPEC_SP |
Enter verbatim response for specialty |
PROVIDED |
?
[F1] |
PREVSAMP |
Compare this provider
((Providers name)) to the listed providers that have been sampled
from this community health center in the past.
|
VER_PREVSAMP |
Were
the previously sampled providers selected
correctly?
|
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?
|
Skip Instructions: |
1: Exit block and goto
BlkBACK.THANK_OOS |
PROV_STRT |
What
is (Provider's name)'s address? |
PROV_STRT2 |
What
is (Provider's name)'s address? |
PROV_CITY |
What is
(Provider's name)'s address? |
PROV_STATE |
What is
(Provider's name)'s address? |
PROV_ZIPCODE |
What is
(Provider's name)'s address? |
PROV_LOCTYPE |
Enter location/address type
|
PROV_PHONE |
What is (Provider's name)'s telephone number? |
PROV_PHTYP |
What type of telephone number is this?
|
GREET_NAME |
Enter
Greet Name |
CALLBACKNOTES |
I'd
like to schedule a DATE to (conduct/complete) the
interview. |
Skip Instructions: |
RF: Goto CBREF |
CBREF |
Exit
this case now. |
THANKCB |
Thank
you. |
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. |
Page
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | CDC User |
File Modified | 0000-00-00 |
File Created | 2021-01-26 |