Attachment 3a
OMB No. XXXX-XXX X
Exp. XX/XX/XXX X
NOTICE - Public reporting burden of this collection of information is estimated to average 10 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).
NAMCS Supplement on Primary Care Policies
TELEPHONE SCREENER
1. Hello, have I reached Dr. {PHYSICIAN NAME}’s office?
YES 1
NO 2 (GO TO 15)
WRONG NUMBER 3 (GO TO 15)
NO LONGER WORKS HERE 4 (GO TO 15)
DECEASED 5 (END STATEMENT 1)
RETIRED 6 (END STATEMENT 1)
NOT IN PRACTICE 7 (END STATEMENT 1)
REFUSED -8
2. This is {INTERVIEWER NAME}. I am calling on behalf of the National Center for Health Statistics regarding a study of physicians. I’d like to confirm that I have the correct office address for Dr. {PHYSICIAN’S NAME}.
[VERIFY ADDRESS AND RECORD ANY CHANGES.]
PRACTICE/CLINIC NAME__________________________
STREET ADDRESS_______________________________
PO BOX/SUITE/ROOM/DEPT/BLDG___________________
CITY, STATE ZIP _________________________________
REFUSED -7
DON’T KNOW -8
3. Is Dr. {PHYSICIAN NAME}’s specialty {SPECIALTY}?
YES 1 (GO TO 5)
NO 2
REFUSED -7 (GO TO 5)
DON’T KNOW -8 (GO TO 5)
4. What is {his/her} specialty?
FAMILY PRACTICE/FAMILY MEDICINE 1
INTERNAL MEDICINE/GENERAL INTERNAL MEDICINE/INTERNIST 2
OTHER, SPECIFY 91 ________________________
REFUSED -7
DON’T KNOW -8
5. Does this practice have a website?
YES 1
NO 2 (GO TO 7)
REFUSED -7 (GO TO 7)
DON’T KNOW -8 (GO TO 7)
6. What is the web address?
WEB ADDRESS__________________________
REFUSED -7
DON’T KNOW -8
7. What is the number of physicians employed at this practice, across all practice locations?
NUMBER _________
REFUSED -7
DON’T KNOW -8
8. Of the total number of physicians at this practice, how many specialize in Family Medicine?
NUMBER _______________
REFUSED -7
DON’T KNOW -8
9. How many specialize in Internal Medicine?
NUMBER ______________________
REFUSED -7
DON’T KNOW -8
10. Does {PHYSICIAN’S NAME} see all {his/her} patients in a hospital?
[IF NEEDED: All patients or only some patients?]
YES 1
NO 2
REFUSED -7
DON’T KNOW -8
11. Does {PHYSICIAN’S NAME} see all {his/her} patients in an urgent or immediate care center?
[IF NEEDED: All patients or only some patients?]
YES 1
NO 2
REFUSED -7
DON’T KNOW -8
12. Does {PHYSICIAN’S NAME} see all {his/her} patients in a Federal facility such as a VA office, a military clinic, or a Public Health Service or Indian Health Service clinic?
[IF NEEDED: All patients or only some patients?]
YES 1
NO 2
REFUSED -7
DON’T KNOW -8
13. Does Dr. {PHYSICIAN’S NAME} see all {his/her} patients in a nursing home, rehabilitation center or correctional facility?
[IF NEEDED: All patients or only some patients?]
YES 1 (END STATEMENT 2)
NO 2 (END STATEMENT 2)
REFUSED -7 (END STATEMENT 2)
DON’T KNOW -8 (END STATEMENT 2)
14. Is {PHONE NUMBER} the best phone number at which to reach Dr. {PHYSICIAN’S NAME}’s office?
[VERIFY AND RECORD ANY CHANGES]
TELEPHONE NUMBER _____________________________________ (END STATEMENT 2)
REFUSED -7 (END STATEMENT 2)
DON’T KNOW -8 (END STATEMENT 2)
15. I’m trying to reach the office of Dr. {PHYSICAN’S NAME} on {STREET} in {CITY, STATE}. Do you know {him/her}?
[IF NEEDED: Do you know {his/her} telephone number/address/the name of a person who might know how to reach {him/her}?]
YES 1 (FOLLOW LEADS, THEN RESTART)
NO 2 (END STATEMENT 1, THEN TO TRACING)
16. Do you have a forwarding telephone number and address for the doctor?
[IF NEEDED: Do you know the name of a person who might know how to reach {him/her}?]
YES 1 (FOLLOW LEADS, THEN RESTART)
NO 2 (END STATEMENT 1, THEN TO TRACING)
END STATEMENT 1: Thank you for your time.
END STATEMENT 2: Those are all the questions I have for you. Thank you for your help.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | HINTS 2007 Main Instrument |
| Author | Chantell Atere |
| File Modified | 0000-00-00 |
| File Created | 2021-01-25 |