Demographic Questionnaire - Healthcare Providers

Form Approved

OMB No: 0920-1091

Exp. Date: 12/31/2018

Attachment 3c: Demographic Questionnaire Healthcare Providers

Demographic Questionnaire: Healthcare Providers

Participant ID:________ Data Collector ID:_______

Date:_________ Start time: __:__am/pm End time:__:__am/pm

Instructions: I am going to hand you a copy of this questionnaire to look at, but I will read each question out loud to you to answer. If there are any questions you would prefer not to answer, you can skip to the next. Remember that your participation is voluntary. These questions are being asked in order to provide context to the interviews.

PROFESSION AND TRAINING

1. What is your profession?

Primary Care Physician or Doctor	1
Infectious Disease/HIV Physician or Doctor	2
Specialty Care Physician or Doctor Please list the specialty:	3
Physician’s Assistant (PA)	4
Nurse Practitioner (NP)	5
Other Please specify:__________________________	9

2. Are you board certified in any of the following? (Select all that apply and indicate year of certification or most recent recertification, if applicable.)

Internal Medicine	1
Family Practice	2
Pediatrics	3
Infectious Diseases	4
Obstetrics and Gynecology	5
Neurology	6
Dermatology	7
Surgery	8
Endocrinology	9
Hematology – Oncology	10
Immunology	11
Other Board Certification Please Specify: ________________________	12

1. In what year did you complete initial board certification? ____________

IF NOT A NURSE PRACTIONER, SKIP TO QUESTION 12

3. Are you certified by the HIV/AIDS Nursing Certification Board as an AIDS Certified Registered Nurse (ACRN) or an Advanced AIDS Certified Registered Nurse (AACRN)?

Yes	1
No	2
N/A	3

4. Are you a member of any of the following professional organizations? (Select all that apply.)

American Academy of HIV Medicine (AAHIVM)	1
HIV Medicine Association (HIVMA)	2
American Association of Nurses in AIDS Care (ANAC)	3
International Association of Providers of AIDS Care (IAPAC)	4

5. Do you have American Academy of HIV Medicine (AAHIVM) specialist certification (AAHIVS)?

Yes	1
No	2

DEMOGRAPHICS

6. What is your age in years? ______________

7. What sex were you assigned at birth, on your original birth certificate? (Check one)

Male	1
Female	2
Refused to answer	99

8. How do you describe your gender identity? (Check all that apply)

Male	1
Female	2
Male-to-female transgender (MTF)	3
Female-to-male transgender (FTM)	4
Other gender identity Please specify:_________________________________	5
Refused to answer	99

9. Which of the following best represents how think of yourself? (Check one)

Gay (lesbian or gay)	1
Straight, this is not gay (or lesbian or gay)	2
Bisexual	3
Something else Please specify:_________________________________	4
Refused to answer	99

10. Are you Hispanic or Latino/a?

No, not Hispanic, Latino/a	1
Yes, Mexican, Mexican American Chicano/a	2
Yes, Puerto Rican	3
Yes, Cuban	4
Yes, Another Hispanic, Latino/a	5
Refused	77

11. What is your race? You may choose more than one option category. (Select all that apply.)

American Indian or Alaska Native	1
Asian	2
Black or African-American	3
Native Hawaiian or other Pacific Islander	4
White	5
Refused	77

12. How long have you been living in [insert city name]?

____________ years _________months

13. How long have you been working as a healthcare provider in the [insert MSA]?

____________ years _________months

1. How long have you been providing HIV-specific services in the [insert MSA]

_______ years _________months

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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-1901)