Provider - Screener

Form Approved

OMB No. 0920-0572

Expiration Date 03/31/2018

Submission under

0920-0572 Health Message Testing System

Attachment 11: Provider In-depth Interview/Focus Group Screener

Public reporting burden of this collection of information is estimated to average 2 hours per response, including the 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 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-0572)

High Impact Prevention Message Testing

Hello, my name is _______________ and I’m from (name of company). We are calling on behalf of RTI International, a non-profit research organization, and the Centers for Disease Control and Prevention. We are not selling or promoting any product. We are calling to recruit physicians to take part in a research study about HIV testing and prevention.

The purpose of the research is to learn physicians’ thoughts on [INSERT TOPIC HERE] being developed for health care providers and involves participating in an interview/focus group. To see if you are eligible for this study, I need to ask you some questions. If you are eligible and choose to be in the study, all of your comments will be kept private. In appreciation for your participation, you will receive $__ [INSERT AMOUNT] as a token of appreciation.

My questions will only take a few minutes. May I proceed?

1. Are you licensed to practice medicine in the US?

NO		TERMINATE
YES		 CONTINUE

2. Are you a MD, DO,RN or PA? [Record] _______________________

3. How many years have you been practicing medicine/providing healthcare services? ______________

< 2		TERMINATE
2 or >		 CONTINUE

4. What is your specialty?

Family Medicine		 CONTINUE TO Q5A
Internal Medicine		 GO TO Q5A
Infectious Disease		 CONTINUE TO Q6
Other_____________		 CONTINUE TO Q5A

ASK FAMILY PRACTICE AND INTERNAL MEDICINE DOCTORS ONLY

5a. Do you have a sub-specialty?

Yes _____  Go to Q7B

No _____  CLASSIFY AS PCP AND CONTINUE TO Q8

5b. What is your sub specialty? _____________________________________
[Check all that apply]

Adolescent medicine

Allergy and immunology

Cardiology

Endocrinology

Gastroenterology

Geriatrics

Hematology

HIV Medicine

Nephrology

Oncology

Pulmonology

Rheumatology

Sports medicine

Other: ___________________

[IF HIV MEDICINE - CLASSIFY AS PCP] [IF “X,” TERMINATE ]

6. In what setting do you see patients? (RECORD ALL THAT APPLY)

Private practice (By private practice, we mean a private physician’s office or group practice.)
Community Hospital
HMO (such as Kaiser)
Academic/University-affiliated hospital
Community Clinic/Health Center	If yes, go to 7a
Government/Military Facility
Other

6a. Does your clinic receive Ryan White funding?

No		CONTINUE
Yes		 CONTINUE

[NOTE: RECRUIT AT LEAST 4 PCPs THAT RECEIVE RYAN WHITE FUNDING]

7. In which of the following settings do you see the largest number of patients? Provide estimated percentages for each that apply.

[RECORD ALL THAT APPLY]

Private practice (By private practice, we mean a private physician’s office or group practice.)
Community Hospital
HMO (such as Kaiser)
Academic/University-affiliated hospital
Community Clinic/Health Center
Government/Military Facility
Other

[NOTE: ATTEMPT A MIX OF PUBLIC AND PRIVATE PRACTICE PHYSICIANS]

8. Approximately how many patients do you have in your current caseload?^

_________

9. Thinking about your current caseload, how many patients that you regularly see in your practice do you treat for HIV or AIDS? ________________

[FOR IDs -- MUST BE “X” OR GREATER TO QUALIFY]

[FOR PCPs –TERMINATE FROM SAMPLE IF LESS THAN X]

9a. What percentage of patients in your total caseload are HIV infected? _________*

10. Are you currently prescribing antiretroviral medications for your patients living with HIV?*

Yes		 CONTINUE
No		 CONTINUE

10a. How many prescriptions do you write a month? __________

11. Do you accept any of the following payment options? (RECORD ALL THAT APPLY)

MEDICAID
MEDICARE

12. [ASK ONLY OF MDs] If private practice, approximately how many total of the following staff are in your private practice/office?

Nurses (RN/LPN)
Nurse Practitioners
Physician Assistants

13. What is the name of your (practice, hospital, clinic, or HMO system)?

___________________________________

14. What is the postal zip code where you primarily practice?

Six- eight digits
Refused

15. Please tell me your age._____________
[Terminate if less than 18, greater than 99]

[NOTE: ATTEMPT A MIX OF AGES]

16. What was your sex assigned at birth?

₁ Male

₂ Female

₂ Intersex

₈ Don’t know

₉ Prefer not to answer

17. Do you consider yourself to be male, female, or transgender? (check only one)

₁ Male

₂ Female

₃ Transgender Man (or Transmale or Transman)

₄ Transgender Woman (or Transfemale or Transwoman)

₈ Don’t know

₉ Prefer not to answer

[NOTE: ATTEMPT A MIX OF GENDERS]

Invitation:

Thank you for answering all of my questions. As I mentioned earlier, we are conducting a research study on behalf of the CDC regarding a [INSERT TOPIC HERE] for providers and would like to hear your professional views. In order to hear them first-hand, we would like to invite you to take part in an informal, personal interview/focus group. The interviews/groups are being scheduled on [DAYS/DATE TBD]. The discussion will last about 1 hour. No one will attempt to sell you anything. As a token of appreciation, you will receive [INSERT TOKEN OF APPRECIATION AMOUNT] at the time of the interview. The interviews will be audio-recorded, and CDC staff may observe the interview. Can we schedule your attendance?

Closing for Ineligible Participants:

Thank you for answering my questions. At this time you are not eligible to be in this study because... We value your interest in this research study. Thank you for being willing to help us.

___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

note to recruiting facility – at the completion of recruitment Detach this page before returning the screeners to rti

Contact Information

Now, let me confirm the spelling of your name, address, and phone number so we can send you directions and a reminder before your scheduled interview time.

Record respondent’s information

Name: Preferred Telephone:

Address:

City, State: Zip:

If you would like, I can also send you a reminder by e-mail.

IF YES: What e-mail address should I use? ________________

If you have any questions or find that you can’t attend, please call us right away at [phone number] so that we can find a replacement. Thank you for your time and for agreeing to help with this important research study.

 Rescreening question to be confirmed prior to start of interview.