Initial Project Phone Call

A

Form Approved

OMB No. 0923-XXXX

Exp. Date xx/xx/20xx

ppendix A – Screening/Initial Phone Call Checklist

Promotion of the National ALS Registry to Non-referral Centers: Checklist for Initial Call to Neurologists’ Offices

Checklist of points to be covered during each initial call to neurologists and neurology practices (all information to be captured in a spreadsheet):

All practices:

• Identify self, where calling from and project

• Identify name and title of person who answered the phone

• Request to speak with an office manager or nurse

• Identify name(s) of neurologist(s) within practice

• Confirm Practice Name

• Determine if the neurologist(s)/practice currently diagnoses and/or cares for ALS patients (if yes = YES practice)

If speaker doesn’t know if the neurologist(s)/practice diagnoses and/or cares for ALS patients:

• Determine if there is someone else that can answer the question

• Thank speaker for their time

YES, practice currently diagnoses and/or cares for ALS patients	No, practice does not currently diagnose and/or care for ALS patients
How many ALS patients have been diagnosed and/or cared for by neurologists at the practice in the past 12 months? (Probes if necessary: small (less than 5 patients per year), medium (5-19), large (20-49), extra-large (50+) (this is to categorize into practice size) Name and info of primary point of contact at practice to ask for during follow-up phone calls Confirm practice contact information Confirm neurologist most likely to diagnose/treat ALS patients at the practice Inform the speaker that a packet of information will be sent to the identified neurologist Thank speaker for their time	Would the neurologist(s) at this practice diagnose and/or care for an ALS patient if one presented at the practice? (if yes = No, But Would practice; if no = No practice)
	If, No But Would practice: Name and info of primary point of contact at practice to ask for during follow-up phone calls Confirm practice contact information Confirm neurologist most likely to diagnose/treat ALS patients at the practice Inform the speaker that a packet of information will be sent to the identified neurologist Thank speaker for their time
	If No: Thank speaker for their time

Public reporting burden of this collection of information is estimated to average 6 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 NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-XXXX).