Form 75 low accuring survey

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

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1 minute of your time.

1 minute per response

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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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If user selects “Yes” to Q14, continue below. If user selects “No”, continue HERE.

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END OF SURVEY

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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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If user selects “Yes” to QS9, continue below. Otherwise continue HERE.

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END OF SURVEY

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END OF SURVEY