Annual FSASC Interview

National Hospital Care Survey

Attachment P- FSASC Induction Form

Annual FSASC Interview

OMB: 0920-0212

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Attachment P: Freestanding Ambulatory Surgery Center Induction Form



National Hospital Care Survey






OMB No. 0920-0212; Expiration date xx/xx/xxxx

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 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).

Notice – Public reporting burden for this collection of information is estimated to average 30 minutes per response, including 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 current valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing burden to: CDC/ATSDR Information Collection Review Office, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0212).






































INTRO_SCR






























Hello (Respondent's name),
This is ... .  I'm calling on behalf of the National Center for Health Statistics, part of the Centers for Disease Control and Prevention concerning their study of ambulatory surgery in freestanding ambulatory surgery centers and in hospitals.  You should have received a letter from Dr. Edward J. Sondik, the Director of the National Center for Health Statistics, describing the National Hospital Care Survey.  Did you receive our letter?
    
  If "No" or "DK", offer to send or deliver another copy.




























1.

Yes




























2.

No




























3.

Unknown

























































INTRO_SCR_PT



















Text:

Hello, this is ...... calling on behalf of the National Center for Health Statistics, part of the Centers for Disease Control and Prevention. If necessary, introduce survey 
We completed part of the interview for the National Hospital Care Survey - Freestanding Ambulatory Surgery Centers and would like to finish it now.




























INTRO_IND





























Text:

o  Identify yourself - show I.D.
o  Ask to speak to:  (Respondent's name)
    (Press ALT-F9 to update Administrator/Alternate contact information)
o  Introduce survey, as necessary




























1.

Continue




























2.

Reluctant Respondent




























3.

Inconvenient time




























4.

Other Outcome




























5.

Conduct/continue induction by phone

























































HELLO





























Text:

Hello.  This is . . . . from calling on behalf of the National Center for Health Statistics, part of the Centers for Disease Control and Prevention. May I speak to (Respondent's name)?




























1.

Correct person, Correct person called to the phone, or call is transferred to correct person




























2.

Unknown/no longer there




























3.

Reached on a different number




























4.

Not available now, not at desk, etc.




























5.

On vacation or otherwise temporarily away from work




























6.

Other outcome or problem interviewing respondent






























TRY_BACK





























Text:

 Do you want to callback later to try and speak to (Respondent's name)
    or do you want to continue with a new/different respondent? REPORTING

PERIOD:  (Reporting period begin date) - (Reporting period end date)




























1.

Callback later




























2.

Continue with new/different respondent

























































KNOWL_RESP



























Text:

Perhaps you can help me.  I am calling on behalf of the National Center for Health Statistics, part of the Centers for Disease Control and Prevention.  May I speak to someone who can answer questions about ambulatory surgery?




























1.

Person you are speaking with can help




























2.

Someone else can help

























































TRANSFER





























Text:

Can you transfer me?




























1.

Yes




























2.

No

























































INTROB





























Text:

((Hello, this is . . . calling on behalf of the National Center for Health Statistics, part of the Centers for Disease Control and Prevention./ ) Is respondent ready to complete the interview?)       




























1.

Continue




























2.

Reluctant Respondent




























3.

Inconvenient time




























4.

Other Outcome

























































NAMECHEK





























Text:

Let me verify that I have the correct name and address for your ASC.
Is the correct name (facility name)?




























1.

Yes




























2.

No

























































ASC_NAME





























Text:

What is your ASC's name?




























1.

Enter 1 to update information




























2.

Continue

























































ADDCHEK





























Text:

Is your ASC located at (Facility Address)




























1.

Yes




























2.

No

























































ASC_ADDRESS























Text:

What is the correct address?




























1.

Enter 1 to update information




























2.

Continue

























































MAILADD





























Text:

Is this the mailing address?




























1.

Yes




























2.

No

























































MASC_STRET





























Text:

What is the correct mailing address?

























































INTRO_AB


























































Text:

(Although you have not received the letter,) I'd like to briefly explain the study to you at this time and answer any questions about it.
The National Center for Health Statistics of the Centers for Disease Control and Prevention is conducting an annual study of ambulatory care.  The study began data collection in 1992. CDC has contracted with Westat to collect the data.  (facility name) has been selected to participate in the study. I am calling to arrange an appointment to discuss your participation. The meeting will take about 30 minutes of your time. The study is authorized under the Public Health Service Act and the information will be held strictly confidential.  Participation is voluntary.
Before discussing the details, I would like to verify our basic information about (facility name) to be sure we have correctly included this ASC in the study.

























































PRFMSURG





























Text:

  Do not ask item if facility is an eye surgery center.
Is ambulatory (outpatient) surgery or ambulatory diagnostic or therapeutic procedures currently performed in this facility?




























1.

Yes




























2.

No




























3.

Eye surgery center

























































THANK_B1





























Text:

Thank you (Respondent's name) but it seems that our information is incorrect. Since (facility name) does not perform ambulatory surgery, it should not have been chosen for our study. Thank you very much for your cooperation.

























































INELSPEC





























Text:

In this study we are excluding facilities that are exclusively dedicated to family planning, birthing, abortion, podiatry or dentistry. Is (facility name) exclusively one of these?




























1.

Yes




























2.

No

























































THANK_B2





























Text:

Thank you (Respondent's name), but it seems that our information is incorrect. Since (facility name)'s specialty is out-of-scope for our study, it should not have been chosen for our study.  Thank you very much for your cooperation.

























































LICASC





























Text:

Is this facility currently licensed by the state?




























1.

Yes




























2.

No

























































PRNTLIC





























Text:

It is important for us to determine whether or not your facility operates under the license or Provider of Services (POS) number of a parent facility.
Does your ASC operate under the license of a parent facility?




























1.

Yes




























2.

No

























































PRNTPOS





























Text:

It is important for us to determine whether or not your facility operates under the license of Provider of Services (POS) number of a parent facility. Does your ASC operate under the Provider of Services (POS) number of a parent facility?




























1.

Yes




























2.

No

























































PARFAC_NAME



























Text:

What is the name of the parent facility? 

























































PARFAC_STRET























Text:

What is the address of (Parent Facility Name)?




























PFNC_THANK





























Text:

Thank you for your time and assistance.
We may contact you again in a few days regarding participation in this study.

























































CALLRO_PFNC























Text:

   Call your RO and inform them of the situation.
     Await resolution from the RO before continuing with this case.
    Situation:  (Operates under a parent facility/Name change/Address change)

























































OWNASC





























Text:

Is this facility owned, operated, or managed by -
     
  Read answer categories




























1.

A hospital




























2.

One or more physicians




























3.

Health maintenance organization




























4.

Another health care provider




























5.

A health care corporation that owns multiple health care facilities (e.g., HCA or Health South)




























6.

Other

























































ONESPEC





























Text:

Is the ambulatory (outpatient) surgery performed here primarily one specialty?




























1.

Yes




























2.

No

























































SPECNAME





























Text:

What is the specialty?




























1.

General Surgery




























2.

Gastroenterology




























3.

Ophthalmology




























4.

Orthopedics




























5.

Plastic Surgery




























6.

Pain Block




























7.

Urology




























8.

Ear, Nose, and Throat (ENT)

9. Obstetrics-Gynecology (OBGYN)

10. Other specialty

























































SPECNAME_SP























Text:

What is the specialty?

























































MULTSPEC





























Text:

Is the ambulatory (outpatient) surgery performed here multi-specialty?




























1.

Yes




























2.

No

























































STUDY_DESC





























Text:

Thank you.  Now I would like to provide you with further information on the study. 
Provide the administrator or other facility representative with a brief description of the study.


As one of the ASC's that has been selected for the study, your contribution will be of great value in producing reliable, national data on ambulatory surgery.


























































INDUCTION_APPT













Text:

I would like to arrange to meet with you so that I can better present the details of the study. Is there a convenient time within the next week or so that I could meet with you? 
 Record day, date and time of appointment ( Enter 999 to start the induction now)




























SCREENER_THK



















Text:

Thank you (Respondent's name) for your cooperation. 
I am looking forward to our meeting.




























ELIGREQ





























Text:

** NOT DISPLAYED **

























































REVIEW





























Text:

I would like to begin with a brief review of the background for this study.
  Provide the administrator or other facility representative with a brief introduction to the study and a general overview of procedures






















































































PERMPART































Text:

As I mentioned earlier, I would like to discuss the plan for conducting the study.  This ASC has been assigned to a (1-month, 2-month, 3-month) data collection period beginning on Monday, (Reporting period begin date). First, I would like to discuss the steps needed to obtain approval for this study. Are there any additional steps needed to obtain permission for the ASC to participate in the study?




























1.

Yes




























2.

No

























































PERMPART_SP



























Text:

Please specify the necessary steps.
  Be sure to ask for the name, title, address and phone of the person(s) able to grant permission






















































































PERM_THANK























Text:

Thank you for your time

























































RO_PERMISSION









Text:

  Call your regional office and inform them of the situation.
    Await guidance before continuing with the case.

























































VSREPPER





























Text:

Now I would like to make arrangements to obtain the information needed for sampling.  I will need to (verify/know) how your ambulatory surgery center is organized and obtain an estimate of the number of patient visits expected during the (1-month, 2-month, 3-month) reporting period.  Would you prefer I (verify/get) this information from you or someone else?




























1.

Respondent




























2.

Someone Else


























































CINFO





























Text:

What is the name of the person I should talk to?
  Enter 1 to enter/update contact person information or change respondent      




























1.

New contact




























2.

Continue interview

























































THANK_RESP





























Text:

Thank you for your time and cooperation.

























































REACH_CPERSON









Text:

  Are the new contacts available to answer the questions at this time? 
    If unavailable, press F10 to set an appointment




























1.

Yes

























































NEWC_INTRO





























Text:

  Read if necessary
Now I would like to obtain the information needed for sampling.  I will need to (verify/know) how your ambulatory surgery center is organized and obtain an estimate of the number of patient visits expected during the (1-month, 2-month, 3-month) reporting period.

























































ASL_INTRO





























Text:

To develop the sampling plan, I would like to (collect/verify) more specific information about this facility's ambulatory surgery (centers/locations).
We are only interested in the following types of (centers/locations):
General or main operating rooms                Endoscopy rooms
Dedicated ambulatory surgery rooms        Cardiac catheterization labs
Satellite operating rooms                              Laser procedures rooms
Cystoscopy rooms                                         Pain block rooms




























1.

Continue




























2.

No in-scope ^centerslocations

























































ASL_NUM





























Text:

** SHOW ONLY **

























































DEL_ASL





























Text:

(Does (ASL name) still exist and is it still operational?)
  (Enter 97 to delete this (ASC/ASL)/(ASC/ASL) entered by mistake/ If Yes, Press ENTER to move to the next row If No, Enter 97 to delete)

























































ASL_NAME





























Text:

(What is the name of the (first/next) ambulatory surgery (center/location)? /Are there any other ambulatory surgery (center/locations)?)
  Enter only IN_SCOPE (ASC/ASL)'s   (Press F1 for in-scope locations)




























ASL_SPEC_GRP



















Text:

What is (name)'s specialty group?




























1.

General




























2.

Multi-specialty




























3.

Gastroenterology




























4.

Ophthalmology




























5.

Orthopedics




























6.

Pain Block




























7.

Plastic Surgery




























8.

Ear, Nose, and Throat (ENT)




























9.

Obstetrics – Gynecology (OBGYN)




























10.

Urology




























11.

Other specialty

























































ASL_EVISITS





























Text:

What is the expected number of ambulatory (outpatient) surgery cases for (name) from (Reporting period begin date) to (Reporting period end date)?

























































CHECK_EVISITS



















Text:

You have indicated that none of your ambulatory surgery (centers/locations) will be seeing patients from (Reporting period begin date) to (Reporting period end date). Is that correct?




























1.

Yes




























2.

No

























































THANK_INELIG



















Text:

Since there are no in-scope ambulatory surgery (centers/locations) for (facility name), it should not have been chosen for our survey.
Thank you very much for your cooperation.

























































ASCLISTA





























Text:

Now I have some questions about generating a report for all ambulatory surgery patients for sampling.
Would you or your IT staff be able to generate a single list of ambulatory surgery cases for any of the following (centers/locations)? 
(Name of all ASLs)




























1.

Yes - All




























2.

Yes - Some Locations




























3.

No

























































ASCLISTB





























Text:

For which of these (centers/locations) can lists be combined? 
     
  Enter all that apply, separate with commas




























1.

ASL_NAME [1]




























2.

ASL_NAME [2]




























3.

ASL_NAME [3]




























4.

ASL_NAME [4]




























5.

ASL_NAME [5]




























6.

ASL_NAME [6]




























7.

ASL_NAME [7]




























8.

ASL_NAME [8]




























9.

ASL_NAME [9]




























10.

ASL_NAME [10]




























11.

ASL_NAME [11]




























12.

ASL_NAME [12]




























13.

ASL_NAME [13]




























14.

ASL_NAME [14]




























15.

ASL_NAME [15]

























































IT_CNAME





























Text:

What is the name of the IT contact?

























































IT_CTITLE





























Text:

What is (IT contact name)'s title?

























































IT_CSTRET





























Text:

What is (IT contact name)'s address?
         Enter number and street or press enter if same

























































IT_CPHONE





























Text:

What is (IT contact name)'s phone number?

























































AU_NUMBER





























Text:

  Assign AU number
    If you can do abstractions for multiple offices in one (center/location), then assign the same AU number to each of those (centers/locations).

























































EBILLRECA





























Text:

Does your ASC submit any CLAIMS electronically (electronic billing)?




























1.

Yes




























2.

No




























3.

Unknown






















































































EMEDRECA





























Text:

Does your ASC use an electronic HEALTH record (EHR) or electronic MEDICAL record (EM) system?  Do not include billing record systems.




























1.

Yes, all electronic




























2.

Yes, part paper and part electronic




























3.

No




























4.

Unknown

























































EHRINSYRA





























Text:

In which year did your ASC install your EHR/EMR system?



























































HHSMUA


















Text:

Does your ASC’s current system meet meaningful use criteria as defined by the Department of Health and Human Services?

















1.

Yes, all electronic

















2.

No

















3.

Unknown



































EHRNAMA13




















































Text:

What is the name of your ASC’s current EHR/EMR system?































































































1.

Allscripts

















2.

Amazing Charts

















3.

athenahealth

















4.

Cerner

















5.

eClinicalWorks

















6.

e-MDs

















7.

Epic

















8.

GE/Centricity

















9.

Greenway Medical

















10.

McKesson/Practice Partner

















11.

Practice Fusion

















12.

NextGen

















13.

Sage/Vitera





































































14.

Other – Specify

















15.

Unknown





































































EHRNAMOTHA
























Description:

Other-Specify name of EHR/EMR system


Other-Specify name of EHR/EMR system























Text:

  Enter name of EHR/EMR system























EHRINSA




























Text:

Does your ASC have plans for installing a new EHR/EMR system within the next 18 months?



























1.

Yes



























2.

No



























3.

Maybe



























4.

Unknown























































EDEMOGA














Text:

Indicate whether your ASC has each of the following computerized capabilities.  Does your ASC have a computerized system for:
   Recording patient history and demographic information?













1.

Yes, used routinely













2.

Yes, but not used routinely













3.

Yes, but turned off or not used













4.

No













5.

Unknown



























EPROLSTA














Text:

Does this include a patient problem list?













1.

Yes, used routinely













2.

Yes, but not used routinely













3.

Yes, but turned off or not used













4.

No













5.

Unknown



























EVITALA














Text:

Recording and charting vital signs?













1.

Yes, used routinely













2.

Yes, but not used routinely













3.

Yes, but turned off or not used













4.

No













5.

Unknown



























ESMOKEA














Text:

Recording patient smoking status?













1.

Yes, used routinely













2.

Yes, but not used routinely













3.

Yes, but turned off or not used













4.

No













5.

Unknown



























EPNOTESA














Text:

 Recording clinical notes?













1.

Yes, used routinely













2.

Yes, but not used routinely













3.

Yes, but turned off or not used













4.

No













5.

Unknown



























EMEDALGA














Text:

Do they include a comprehensive list of the patient's medications and allergies?













1.

Yes, used routinely













2.

Yes, but not used routinely













3.

Yes, but turned off or not used













4.

No













5.

Unknown













ECPOEA














Text:

Ordering prescriptions?













1.

Yes, used routinely













2.

Yes, but not used routinely













3.

Yes, but turned off or not used













4.

No













5.

Unknown



























ESCRIPA














Text:

Are prescriptions sent electronically to the pharmacy?













1.

Yes, used routinely













2.

Yes, but not used routinely













3.

Yes, but turned off or not used













4.

No













5.

Unknown



























EWARNA














Text:

Are warnings of drug interactions or contraindications provided?













1.

Yes, used routinely













2.

Yes, but not used routinely













3.

Yes, but turned off or not used













4.

No













5.

Unknown



























EREMINDA














Text:

Indicate whether your ASC has each of the following computerized capabilities.  Does your ASC have a computerized system for:

Providing reminders for guideline-based interventions or screening tests?













1.

Yes, used routinely













2.

Yes, but not used routinely













3.

Yes, but turned off or not used













4.

No













5.

Unknown



























ECTOEA














Text:

Ordering lab tests?













1.

Yes, used routinely













2.

Yes, but not used routinely













3.

Yes, but turned off or not used













4.

No













5.

Unknown



























EORDERA














Text:

Are orders sent electronically?













1.

Yes, used routinely













2.

Yes, but not used routinely













3.

Yes, but turned off or not used













4.

No













5.

Unknown









































ERESULTA














Text:

Indicate whether your ASC has each of the following computerized capabilities.  Does your ASC have a computerized system for:

Viewing lab results?













1.

Yes, used routinely













2.

Yes, but not used routinely













3.

Yes, but turned off or not used













4.

No













5.

Unknown



























EGRAPHA














Text:

Can the EHR/EMR automatically graph a specific patient's lab results over time?













1.

Yes, used routinely













2.

Yes, but not used routinely













3.

Yes, but turned off or not used













4.

No













5.

Unknown



























EIMGRESA














Text:

Indicate whether your ASC has each of the following computerized capabilities.  Does your ASC have a computerized system for:

Viewing imaging results? 













1.

Yes, used routinely













2.

Yes, but not used routinely













3.

Yes, but turned off or not used













4.

No













5.

Unknown



























EPTEDUA
















Text:

Indicate whether your ASL has each of the following computerized capabilities. Does your ASC have a computerized system for: Identifying education resources for specific patient conditions? 















1.

Yes, used routinely















2.

Yes, but not used routinely















3.

Yes, but turned off or not used















4.

No















5.

Unknown





























ECQMA














Text:

Reporting clinical quality measures to federal or state agencies (such as CMS or Medicaid)?













1.

Yes, used routinely













2.

Yes, but not used routinely













3.

Yes, but turned off or not used













4.

No













5.

Unknown



























EGENLISTA














Text:

Generating lists of patients with particular health conditions?













1.

Yes, used routinely













2.

Yes, but not used routinely













3.

Yes, but turned off or not used













4.

No













5.

Unknown



























EIMMREGA














Text:

Electronic reporting to immunization registries? 













1.

Yes, used routinely













2.

Yes, but not used routinely













3.

Yes, but turned off or not used













4.

No













5.

Unknown









































ESUMA














Text:

Indicate whether your ASC has each of the following computerized capabilities.  Does your ASC have a computerized system for:
   Providing patients with clinical summaries for each visit?













1.

Yes, used routinely













2.

Yes, but not used routinely













3.

Yes, but turned off or not used













4.

No













5.

Unknown



























EMSGA














Text:

Exchanging secure messages with patients?













1.

Yes, used routinely













2.

Yes, but not used routinely













3.

Yes, but turned off or not used













4.

No













5.

Unknown



























EHLTHINFOA














Text:

Providing patients with an electronic copy of their health information?













1.

Yes, used routinely













2.

Yes, but not used routinely













3.

Yes, but turned off or not used













4.

No













5.

Unknown



























EPTRECA
















Text:

Providing patients the ability to view online, download or transmit information from their medical record?















1.

Yes, used routinely















2.

Yes, but not used routinely















3.

Yes, but turned off or not used















4.

No















5.

Unknown































EMEDIDA
















Text:

Reconciling lists of patient’s medications to identify the most accurate list?















1.

Yes, used routinely















2.

Yes, but not used routinely















3.

Yes, but turned off or not used















4.

No















5.

Unknown
















ESHAREA




Text:

Does your ASC share any patient health information electronically (not fax) with other providers, including hospitals, ambulatory providers, or labs?













1.

Yes













2.

No



























ESHAREHOWA


Text:

How does your ASC electronically share patient health information?
    Enter all that apply, separate with commas













1.

EHR/EMR













2.

Web portal (separate from EHR/EMR)













3.

Other electronic method: ___________________




























ESHAREHOWOTHA

































Text: Specify other electronic method
































LABRESA














Text:

Please indicate whether your ASC electronically (not fax) shares each of the following types of health data and with which types of health care providers. Lab results?
  Enter all that apply, separate with commas













1.

Hospitals with which your ASC is affiliated













2.

Ambulatory providers inside your ASC













3.

Hospitals with which your ASC is not affiliated













4.

Ambulatory providers outside your ASC



























IMAGREPA














Text:

Imaging reports?
  Enter all that apply, separate with commas













1.

Hospitals with which your ASC is affiliated













2.

Ambulatory providers inside your ASC













3.

Hospitals with which your ASC is not affiliated













4.

Ambulatory providers outside your ASC



























PTPROBA














Text:

Patient problem lists?
  Enter all that apply, separate with commas













1.

Hospitals with which your ASC is affiliated













2.

Ambulatory providers inside your ASC













3.

Hospitals with which your ASC is not affiliated













4.

Ambulatory providers outside your ASC



























MEDLISTA














Text:

Medication lists?
  Enter all that apply, separate with commas













1.

Hospitals with which your ASC is affiliated













2.

Ambulatory providers inside your ASC













3.

Hospitals with which your ASC is not affiliated













4.

Ambulatory providers outside your ASC



























ALGLISTA














Text:

Medication allergy lists?
  Enter all that apply, separate with commas



















1.

Hospitals with which your ASC is affiliated



















2.

Ambulatory providers inside your ASC



















3.

Hospitals with which your ASC is not affiliated



















4.

Ambulatory providers outside your ASC















































MUINCA




























Text:

Medicare and Medicaid offer incentives to practices that demonstrate “meaningful use of health IT”. Does your ASC have plans to apply for these incentive payments?



























1.

Yes, we already applied



























2.

Yes, we intend to apply



























3.

Uncertain whether we will apply



























4.

No, we will not apply





























MUYEARA



































Text:

If MUINC = 1 or 2

When did your ASC first apply or when does your ASC first intend to apply?

































1.

2011

































2.

3.

2012

2013

































4.

2014 or later

































5.

Unknown




































REMACCA If PAYHITA=1

Text: Now I’d like to ask you some questions about your ASC’s electronic health records system. Can this system be accessed from the outside by entities not associated with the ASC?

  1. Yes

  2. Unsure (will have to check and get back to interviewer)

  3. No – Skip to ASL_SPEC_GRP

  4. Unknown



REMREPA Text: Would your ASC be willing to allow CDC’s contractor to obtain password access to your ASC’s electronic health records system and load the charting software onto desktop computers at their headquarters? The contractor’s Data Security Plan complies with all relevant laws, regulations, and policies governing the security of data and protection of confidentiality.

  1. Yes

  2. Unsure (will have to check and get back to interviewer)

  3. No

  4. Unknown
























































ASL_SPEC_GRP






















Text:

** SHOW ONLY **



























1.

General



























2.

Multi-specialty



























3.

Gastroenterology



























4.

Ophthalmology



























5.

Orthopedics



























6.

Pain Block



























7.

Plastic Surgery



























8.

Ear, Nose and Throat



























9.

Obstetrics - Gynecology



























10.

Urology



























11.

Other specialty























































ASL_STRET




























Text:

What is (name)'s address or the address where the abstractions will be done?
  (Abstractions can be done at one location for multiple ASL's)























































ASL_PHONE




























Text:

What is (name)'s telephone number or the telephone number where the abstractions will be done?























































ASL_CONTACT


























Text:

  Enter ambulatory surgery (center/location) contact person's name       



























TE




























Text:

** NOT DISPLAYED **























































RS




























Text:

** NOT DISPLAYED **























































TOTAL_VISITS


























Text:

** NOT Displayed **























































PRF_WKLD




























Text:

** NOT DISPLAYED **























































MULTIASCFLAG










Text:

** Not Displayed **























































EXIT_REFUSAL






















Text:

  Are you exiting this case because of a refusal?



























1.

Yes, potential refusal



























2.

No























































CALLBACKNOTES






Text:

I'd like to schedule a DATE to (conduct the interview/complete the interview/follow-up on missing items) the interview.
What DATE AND TIME would be best to visit again?
        
  Today is:  ^IntDate                        



























THANKCB




























Text:

Thank you. I will call/come back at the time suggested
   
  Revisit   (Appointment information)



















































































THANKYOU




























Text:

This concludes the interview.  Thank you for your patience, and for taking the time to answer our questions.



























ELIGFS




























Text:

  Does this facility have an eligible ASC?



























1.

Yes



























2.

No























































VSFS101




























Text:

How many visits are expected during the reporting period?























































VSFSLY




























Text:

How many visits were there to this ASC last year?























































REFUSE




























Text:

** Not Displayed **























































WHOMAS




























Text:

  By Whom?



























1.

ASC administrator



























2.

ASC Director



























3.

Approval board or official



























4.

Other ASC official























































TELPERAS




























Text:

  Was the refusal by telephone or in person?



























1.

Telephone



























2.

In Person























































REASONAS




























Text:

  What reason was given?























































CONVAS




























Text:

  Was conversion attempted?



























1.

Yes



























2.

No

























































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