Follow-Up Phone Call (Three Months Post-Mailing)

Appendix G – Follow-up Phone Call #2 Checklist

Promotion of the National ALS Registry to

N

Form Approved

OMB No. 0923-XXXX

Exp. Date xx/xx/20xx

on-referral Centers: Checklist for Follow-up Call Three Months Post-mailing to Neurologists’ Offices

Checklist of points to be covered during each follow-up call to neurologists and neurology practices three months after the mailing (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 previous point of contact

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

• Remind contact we are calling about the mailing from three months ago

• Do you remember receiving a mailing about the National ALS Registry?

• Did you read the Provider Guide?

• Did you hang the poster?

  • If yes, where?

• Did you see any ALS patients in the past 3 months?

• Did you hand out the Patient Guide?

  • To whom, patient or care-giver?

• Did you order additional Registry materials on the ATSDR web site?

• Did you advise any ALS patients to self-enroll in the Re

• Did you help any ALS patients self-enroll in the Registry?

• Did you complete the continuing education module?

• Ask if there are any questions

• Provide our contact information for any questions

• Thank speaker for their time

Public reporting burden of this collection of information is estimated to average 3 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).