Physician Cognitive Testing Screener

Attachment 4b

OMB No. xxxx-xxxx:

Expires: xx/xx/XXXX

NOTICE - Public reporting burden of this collection of information is estimated to average 5 minutes 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 Information Collection Review Office; 1600 Clifton Road, 1600 Clifton Road, MS D-17, 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). Screening Instrument for Physician Cognitive Testing

COGNITIVE TESTING SCREENER

Hello __________;

Thank you for your interest in participating in the NAMCS Supplement on Primary Care Policies. I will need some background information from you to see if you qualify.

(Ask if not known)

1. Is this a primary care practice that treats adults?

2. What is the name of your primary care practice?

3. What is the address for the practice location where you work the most?

4. Is your practice:

single specialty primary care,

multispecialty with at least one primary care physician, or

other?

5. Is your practice multisite or single site?

6. If multisite, how many practice locations?

7. Which one of the following best describes your position in this medical practice?

Physician practice owner or partner,

head of practice,

family practice physician,

internal medicine physician specializing in primary care,

physician not specializing in primary care,

physician not specializing in primary care,

medical resident, or

other?

8. How many primary care physicians work in your practice (across all locations)?

9. Who owns this practice?

A physician or physician group,

hospital or hospital system,

health maintenance organization (HMO),

insurance company,

university or medical school,

state or local government, or

other?

10. How long have you worked in this practice?

11. In what year did you receive your medical degree?

12. What is your sex?

13. How did you hear about this study?

14. Would you prefer to be contacted via telephone or email to follow up on this study?

15. What is the best phone number and/or email at which to reach you?

16. What is the best time to contact you if reaching you by phone?

17. Once the data collection is completed the information will be transferred to NCHS.

We are currently compiling a list of possible interview candidates. Once that is complete, we will begin scheduling interviews, and get back to you as soon as possible.

I look forward to hearing from you. Thank you again for your assistance!