Form 74 Prospective Survey

OMB #0925-xxxx
Expiration Date: xx/xx/xxxx

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take 1 minute

1 minute of your time.

1 minute

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Note: Q1a appears only if “My practice is located within a community hospital” is
selected for Q1.
If user selects “physician” to Q3, continue below. If user selects “Staff
member/other”, continue HERE.

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Note: This 8a appears if the user selects either of the two leftmost radio buttons for
Q8.

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Note: This Q8a appears if the user selects any of the three rightmost radio buttons
for Q9.

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END OF SURVEY

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Note: Q1a appears only if “My practice is located within a community hospital” is
selected for Q1.

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Note: This QS2 appears if the user selects either of the two leftmost radio buttons
for QS2.

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Note: This QS2 appears if the user selects any of the three rightmost radio buttons
for QS2.

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