Form 1 Draft Workforce Safety Cognitive Interview Guide

Pilot Test of the Proposed Workforce Safety Supplemental Item Set for the Surveys on Patient Safety Culture™, Supporting Statement A

Attachment B: Draft Workforce Safety Cognitive Interview Guide

Form Approved
OMB No. XXXX-XXXX
Exp. Date XX/XX/20XX

Draft Workforce Safety Supplemental Item Set

Cognitive Interview Guide

8/3/2020

Public reporting burden for this collection of information is estimated to average 60 minutes per response, the estimated time required to complete the interview. 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: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

Draft Workforce Safety Supplemental Item Set: Cognitive Interview Guide

Respondent ID#:	Interviewer:
Respondent Job Title:	Note Taker:
Date & Time of Interview:	Tape Recorded?

Introduction and Oral Consent

Hello, my name is _____________________________. I have [a/two] colleague(s) with me here [NAME(S)]. We work for Westat, a private research company in Rockville, Maryland. Thank you for taking the time to complete the survey and talk with us.

Westat is developing survey questions for the Agency for Healthcare Research and Quality, part of the U.S. Department of Health and Human Services, that ask about the culture in [hospitals/nursing homes/facility]. You recently completed a set of draft survey questions for this survey.

I am talking with you today to find out how the survey questions worked for you – for example, were the questions easy to understand and answer? Were any of the words vague or confusing? I am interested in what you think about the questions, and I will be asking you what the questions mean to you. There are no right or wrong comments.

We take many steps to keep your comments and survey responses private. I will discuss your responses only with other project team members. We will not include your name or the name of your facility in any written findings or reports. We may include quotes in our internal notes to help us understand better the phrasing you and others use to describe your experiences.

This is a research project and your participation is voluntary. There are minimal risks and no direct benefits to participating in this study. You may skip any question that you do not want to answer and you may stop the interview at any point. I expect the interview to take about 1 hour.

I am happy to answer any questions you may have about this task. If you have any questions about your rights as a research participant, you may contact Westat’s Human Subjects Protections office. Would you like that phone number? (IF YES: Please call 1-888-920-7631 and leave a message with your full name, the name of this research study “Diagnostic Safety Survey Items”, and a phone number beginning with the area code. Someone will return your call as soon as possible).

Next, we will walk through parts of the survey and I’d like for you to tell me about how you decided on your answers and any other reactions you had to the questions. I’ll also ask you some specific questions to help us better understand how the survey is working. Your comments will help us to identify possible problems [IF APPLICABLE: and thank you for providing some of those comments on the survey in the boxes we provided]. Please don’t hesitate to share any thoughts, bring up problems, suggest wording changes, or say which items you prefer – the purpose of this interview is to improve the survey items and make sure they make sense.

Do you have a copy of your survey? OK Great – we are only going to review a portion of the survey; we will start with the section on page 8.

Because I want to pay close attention to what you say, I would like to tape record our interview so that I can listen to it later to see if I missed anything. Is that okay?

PRESS *2 TO START RECORDING [NOTE TAKERS SHOULD START THEIR SEPARATE RECORDING DEVICE]: I need to ask your permission again so that it is recorded: Today is mo/day/year at [time]. Do you agree to participate in this interview and to have it audio recorded? …Great, Thank you. Before we start, do you have any questions? Okay, let’s begin.

GENERAL INTERVIEWER INSTRUCTIONS:

-START EACH QUESTION EVALUATION BY ADDRESSING ANY WRITTEN COMMENTS, THEN FOLLOW UP AS NECESSARY WITH A GENERAL PROBE ABOUT THE PARTICIPANTS ANSWER (e.g. – Can you tell me how you chose your answer for…)

-CONTINUE WITH SCRIPTED PROBES OR UNSCRIPTED PROBES AS NECESSARY TO EVALUATE THE PARTICIPANT’S COMPREHENSION & RESPONSE

-PAY PARTICULAR ATTENTION TO ATYPICAL RESPONSES SUCH AS DK/NA, NEITHER…, OR DISAGREE (OR AGREE FOR NEG. WORDED ITEMS)

-IF YOU THINK A RESPONDENT EXPERIENCED A PROBLEM ANSWERING THE QUESTION (OR THE QUESTION HAS A PROBLEM IN NEED OF ATTENTION), MARK THAT QUESTION AND WRITE UP THE PROBLEM IMMEDIATELY FOLLOWING THE INTERVIEW

COVID BACKGROUND QUESTIONS

Instruction and Definition	Interviewer Script, Probes, and Notes
PRELIMINARY QUESTIONS	Before we dive in to the survey content, can you tell me about how your [UNIT/NURSING HOME/FACILITY] is adjusting to the COVID-19 pandemic? How has your workflow changed, if at all? Have these changes affected the quality or type of care that you provide? how so? Is your office providing COVID testing? We’re curious how your facility’s experience with COVID affected your answers to the survey, so please mention when this happened as we walk through the survey questions. Do you work at multiple locations? [IF YES] How did you reflect that in your survey responses?

Section A: Safe Patient Handling (scale: Strongly Disagree – Strongly Agree)

Draft Items	Interviewer Script, Probes, and Notes
	The first section we will review is called Safe Patient Handling – did you feel as though the questions in this section applied to you? How about in general to your [UNIT, NURSING HOME, ASC]? What types of equipment were you thinking about while answering this section?
In this [unit/nursing home/facility], equipment needed to help lift or move patients is readily available.	Can you tell me how you chose your answer for the first question? What does it mean for equipment….to be readily available?
In this [unit/nursing home/facility], staff use equipment for moving patients when necessary.	Can you tell me how you chose your answer for the next one? Do staff ever not use equipment for moving patients when they should? Do staff manually move patients when they should use equipment?
In this [unit/nursing home/facility], staff are encouraged to use available patient lifting and transfer equipment even if it means taking more time.	Can you tell me about your answer for the next one? IF AGREE: Can you say more about how staff are “encouraged to…..?
Staff appropriately use safe patient handling and mobility technology (including patient lifts and transfer devices) to transfer, lift, or reposition patients.	Can you tell me how you chose your answer for question 3? IF DISAGREE: Do staff use this equipment at all? [OR DO THEY USE IT, BUT NOT APPROPRIATELY?]? IF AGREE: Can you say more about how staff “appropriately use…” What would it mean to not appropriately use…. Is that ever the case at your location?
In this [unit/nursing home/facility], staff understand how to use safe patient handling equipment (including patient lifts and transfer devices).	Can you tell me how you chose your answer for the next one? This question asks whether staff understand how to use safe patient handling equipment – what types of equipment were you thinking about? IF > 1 type: Does your answer apply the same to all of these?

Section B: Slips, Trips, Falls, Spills, Hazards (scale: Strongly Disagree – Strongly Agree)

Draft Items	Interviewer Script, Probes, and Notes
	Now let’s look at the next section about Slips, Trips, Falls, Spills, Hazards
In this [unit/nursing home/facility], regular assessments are conducted to identify hazards that could lead to slips, trips, and falls.	Can you tell me how you chose your answer for the first question? IF AGREE: Can you say more about these regular assessments? How regular are they? Who conducts these assessments? What parts of the [unit / nursing home / facility ] are assessed? And what happens with the results?
In this [unit/nursing home/facility], unsafe conditions and other hazards regularly cause staff to slip, trip, or fall. (negatively worded)	[DID THEY NOTICE NEGATIVE WORDING?] Can you tell me how you chose your answer for the next question? IF AGREE: How regularly do unsafe conditions/hazards case staff to slip, trip, or fall? [ARE THEY THINKING SPECIFICALLY ABOUT STAFF, OR ALSO MENTIONING PATIENTS?]

Section C: Personal Protective Equipment (PPE)/Exposure (scale: Strongly Disagree – Strongly Agree)

Draft Items	Interviewer Script, Probes, and Notes
Providers and staff feel comfortable asking for personal protective equipment (PPE) if it is not available.	Can you tell me how you chose your answer for the next question? How often is PPE not available when needed in your [UNIT/NURSING HOME/FACILITY]? Did you answer based on your own behavior, others behavior, or both? IF OTHERS/BOTH: Did you feel as though you could answer this question on behalf of others in your group? [ARE THEY AWARE THAT OTHERS ARE COMFORTABLE ASKING…?]
Providers and staff properly use personal protective equipment (PPE) when it is needed.	Can you tell me how you chose your answer for the first question? What does it mean to properly use PPE? Is there any difference between how providers and/or staff use PPE in your [unit/facility]?
This [hospital/nursing home/facility] has effective procedures to limit provider and staff exposure to harm from blood borne pathogens and infectious diseases.	Can you tell me how you chose your answer for the next question? IF AGREE: Can you say more about these procedures…? How do you know that they’re effective?
When providers or staff are exposed to blood borne pathogens or infectious diseases, they follow appropriate procedures to reduce their risk of harm.	Can you tell me how you chose your answer for the next question? How often are providers/staff exposed to blood borne pathogens or infectious diseases in your [UNIT/NURSING HOME/FACILITY]? What procedures do they need to follow? Is it different for providers vs. staff?
Management is responsive when providers and staff need additional personal protective equipment.	Can you tell me how you chose your answer for the next question? IF AGREE: Can you provide an example of how management was responsive when…? This question asks about ‘management’ – who were you thinking about when answering this question? Did you include your immediate manager/supervisor or upper management/administration/c-suite, or both? How do you interpret additional PPE, more? or different kinds? Or both?
Management is responsive when providers and staff report concerns about personal protective equipment.	Can you tell me how you chose your answer for the next question? IF AGREE: Can you provide an example of how management was responsive when…? How do staff report concerns…? Do you think this question is the same or different from the one above?

Section D: Sharps (scale: Strongly Disagree – Strongly Agree)

Draft Items	Interviewer Script, Probes, and Notes
	Let’s move on to the next section… This section is titled ‘Sharps’ – is that a term you use in your [UNIT/NURSING HOME/FACILITY]? Did you think the questions in this section were relevant to your [UNIT/NURSING HOME/FACILITY]?
Providers and staff in this [unit/nursing home/facility] carefully follow procedures to prevent injuries from contaminated sharp objects such as used needles and scalpels.	Can you tell me how you chose your answer for the first question? What does contaminated mean in this question? Is there a better way to describe this?
This [unit/nursing home/facility] has an effective sharps injury prevention program.	Can you tell me how you chose your answer for 2? IF AGREE: Can you say more about the injury prevention program? How would you say that it’s effective or not?
In the event of a sharps injury, providers and staff know the steps to take to reduce their risk of contracting blood borne pathogens/infectious diseases.	Can you tell me how you chose your answer for 3? This question asks about what providers and staff know… did you feel like you could answer on behalf of the others in your unit/facility? Are the steps different for providers vs. staff?

Section E: Workplace Violence (scale: Strongly Disagree – Strongly Agree)

Draft Items	Interviewer Script, Probes, and Notes
	Let’s move on to the next section titled ‘Workplace Violence”
Psychological or verbal aggression includes abusive, intimidating or harassing behavior and threats. There is a problem with psychological or verbal aggression by those working in this [unit/nursing home/facility] (negatively worded)	How about the next question? Did you read the description of ‘Psychological or verbal aggression? What’d you think about it? Do any of these types of things effect happen in your [UNIT/NURSING HOME/FACILITY]? IF YES – Would you mind giving an example? IF DISAGREE: What would it mean for there to be a problem with ‘Psychological or verbal aggression in your [UNIT/NURSING HOME/FACILITY]? Is psychological or verbal aggression a problem from patients? Is it more of a problem from co-workers/supervisors/doctors in your facility, or from patients?
There is a problem with disruptive/disrespectful behavior by those working in this [unit/nursing home/facility] (negatively worded)	Can you tell me how you chose your answer for the first question? Did you read the description of ‘disruptive or disrespectful behavior’? What’d you think about it? Do any of these types of things effect happen in your [UNIT/NURSING HOME/FACILITY]? IF YES – Would you mind giving an example? IF DISAGREE: What would it mean for there to be a problem with ‘disruptive or disrespectful behavior’ in your [UNIT/NURSING HOME/FACILITY]?
There is a problem with unwanted physical contact from patients/visitors in this [unit/nursing home/facility] (negatively worded)	Does physically violent behavior ever happen in this unit/facility? IF YES – Would you mind giving an example? [DO THEY NOTICE THIS QUESTION IS ABOUT PATIENTS/VISITORS, WHILE 1 & 2 ARE ABOUT ‘THOSE WORKING IN THIS [UNIT/FACILITY]’] What does “unwanted physical contact” mean in this question? Please provide some examples.
This [unit/nursing home/facility] has measures/systems in place to properly/effectively respond to situations involving physically violent patients/visitors.	Can you tell me about your answer for last question in the section? How often are there physically violent patients/visitors in your [UNIT/FACILITY]? IF AGREE: Can you say more about these measures/systems? IF DISAGREE: Do you have any measures or systems in place to…?

Section F: STRESS/BURNOUT (scale: Strongly Disagree – Strongly Agree)

Draft Items	Interviewer Script, Probes, and Notes
	NOTE: TWO VERSIONS OF EACH QUESTION ARE INCLUDED IN EACH BOX – ONE THAT FOCUSES ON THE RESPONDENT AND THE OTHER, WHICH FOCUSES COLLECTIVELY. The questions in this section are about stress/burnout… Did you feel as though you could answer these questions on behalf of how others feel in your unit/facility?
I feel a great deal of stress on the job/during my workday. Providers and staff in this [unit/nursing home/facility] feel a great deal of stress on the job. (negatively worded)	Can you tell me how you chose your answer for the first question? COLLECTIVE: How do you know whether providers and staff feel a great deal of stress on the job? Is this something you discuss with others?
I feel emotionally drained from my work. Providers and staff feel emotionally drained from their work. (negatively worded)	Can you tell me about your answer for the next question? IF DISAGREE: What would it mean to you to feel ‘emotionally drained from your work’? COLLECTIVE: How do you know whether providers and staff are emotionally drained from their work? Is this something you discuss with others?
I am often assigned a higher workload than I am comfortable with. We often have such a heavy workload that we are constantly rushing. (negatively worded)	Can you tell me about your answer for the next question? How are workloads assigned in your [unit/facility]?
I don’t have time to take enough rest breaks at work. We don’t have time to take enough rest breaks at work. (negatively worded)	Can you tell me about your answer for the next question? COLLECTIVE: How do you know whether others have time to take enough rest breaks at work? Is this something you discuss with others?
I feel burned out from my work. Providers and staff in this [unit/nursing home/facility] feel burned out from work. (negatively worded)	Can you tell me about your answer for the next question? IF AGREE: What does it mean to feel burned out from your work? IF DISAGREE: What would it mean to feel burned out from your work? COLLECTIVE: How do you know whether providers and staff feel burned out from work? Is this something you discuss with others?
IF PERSONAL: This section asks about how you feel personally about stress/burnout, do you think your answers would change or stay the same if you were answering on behalf of everyone who works in your [unit / nursing home / facility]? Can you say more about that? Do you think you could answer these questions on behalf of others in the office? Could you say more about that? IF COLLECTIVE: This section asks about the feelings of providers and staff in your [unit / nursing home / facility], do you think your answers would change or stay the same if you were answering just based on your own personal feelings? Can you say more about that? Did you feel comfortable answering these questions on behalf of your entire [unit / nursing home / facility ] ? Can you say more about that?

Section G: Management Support for Workplace Health and Safety (scale: Strongly Disagree – Strongly Agree)

Draft Items	Interviewer Script, Probes, and Notes
	This whole section asks about management – were you thinking about the same or different management as the early sections? Did you change who you were thinking about as you answered the questions in this section?
Management in this [unit/nursing home/facility] responds to provider and staff concerns about work-related stress/burnout.	Can you tell me how you chose your answer for the first question? IF AGREE: Can you provide an example of how management is responsive to provider and staff concerns about work-related stress/burnout?
Management is genuinely concerned about the well-being of everyone who works here.	Can you tell me how you chose your answer for this question? How do you know that management is genuinely concerned about the well-being of everyone who works here?
Unsafe working conditions/workplace safety hazards are quickly corrected when they are brought to management’s attention.	Can you tell me how you chose your answer for the next question? Can you provide an example or two of what you think of as ‘unsafe working conditions or workplace safety hazards”? are these the same thing or different? IF AGREE: Can you provide an example of when this happened?
Management in this [unit/nursing home/facility] takes action to address workforce safety concerns that are brought to their attention.	Can you tell me how you chose your answer for the next question? This question uses the term ‘workforce safety concerns’ - what does this phrase mean to you? Can you provide an example of a workforce safety concern? [Is it the same as unsafe working conditions/workplace safety hazards]? IF AGREE: Can you provide an example of when this happened?
Management is quick to respond to workplace safety concerns.	Can you tell me how you chose your answer for the next question? IF AGREE: Can you provide an example of when this happened? Tis question uses the term ‘workplace safety concerns’ – what does this phrase mean to you? Is it the same or different from the phrase ‘workforce safety concerns’ that we used in the last question?
Management regularly monitors the workplace to identify and correct unsafe working conditions.	Can you tell me how you chose your answer for the next question? IF AGREE: How often do they regularly monitor the workplace…?
Management in this [unit/nursing home/facility] encourages staff to voice their concerns about workplace safety.	Can you tell me how you chose your answer for the next question? What were you thinking about when you read ‘concerns about workplace safety’? IF AGREE: Can you provide an example of how management encourages staff to voice their concerns about workplace safety?
Management in this [unit/nursing home/facility] takes staff concerns about workplace safety seriously.	Can you tell me how you chose your answer for the next question? IF AGREE: Can you say more about how management takes staff concerns…seriously?
Providers and staff trust that management will do the right thing to keep workers safe.	Can you tell me how you chose your answer for the next question? Can you say in your own words what this question is asking?

Section H: Speaking Up (scale: Strongly Disagree – Strongly Agree)

Draft Items	Interviewer Script, Probes, and Notes
Staff in this [unit/nursing home/facility] inform their supervisor as soon as possible when they notice a workplace safety hazard.	Can you tell me how you chose your answer for the next question? Can you provide an example of a workplace safety hazard? How often do staff report work place hazards? Are all hazards reported, or are some just corrected without reporting them? Are these hazards typically reported as soon as possible or at a later time?
In this [unit/nursing home/facility], staff speak up if they see something that may negatively affect workplace safety.	Can you tell me how you chose your answer for the next question? This question asks about the actions of staff in your unit/facility - Did you feel like you could answer on behalf of others in your [UNIT/FACILITY]?
In this [unit/nursing home/facility], staff are afraid to voice their concerns about workplace safety. (negatively worded)	Can you tell me how you chose your answer for the next question? This question asks about the feelings of staff in your unit/facility - Did you feel like you could answer on behalf of others in your [UNIT/FACILITY]? What makes staff afraid to voice concerns about workplace safety?
Staff in this [unit/nursing home/facility] tell other staff who are doing something unsafe to stop.	Can you tell me how you chose your answer for the first question? How often has this type of thing happened in your unit/facility? IF AGREE: Can you provide an example of when this has happened?

Section I: Reporting of Workplace Safety Incidents

Draft Items	Interviewer Script, Probes, and Notes
In the past 12 months, have you experienced one or more workplace physical injuries or harm from any of the following? Lifting patients or equipment A slip, trip, or fall A used sharp object like a needle or scalpel Hazardous materials, pathogens, and/or contagious diseases Physical violence from others [Yes, and I reported ALL incidents/ Yes, and I reported SOME incidents/ Yes, but I DID NOT report any of these incidents/ No, I did not experience any injuries or harm from these types of incidents]	Can you say more about your answer to the first question? IF YES, REPORTED – PROBE CAREFULLY TO GET BACKGROUND ON THE INCIDENT(S) IF YES, NOT REPORTED – PROBE CAREFULLY TO UNDERSTAND WHY THE EVENT WAS NOT REPORTED IF NO – Are physical injuries or illnesses stemming from your workplace common? IF > NEVER, How often are they reported?
In the past 12 months, have you experienced one or more incidents involving workplace disruptive behavior or psychological or verbal aggression? [Yes, and I reported ALL incidents/ Yes, and I reported SOME incidents/ Yes, but I DID NOT report any of these incidents/ No, I did not experience any injuries or harm from these types of incidents]	Can you tell me how you chose your answer for the next question? IF YES, REPORTED – PROBE CAREFULLY TO GET BACKGROUND ON THE INCIDENT(S) IF YES, NOT REPORTED – PROBE CAREFULLY TO UNDERSTAND WHY THE EVENT WAS NOT REPORTED IF NO – Are these types of incidents common in your workplace ? IF > NEVER, How often are they reported?
In this [unit/nursing home/facility], reporting of worker injuries and health concerns is encouraged.	Can you tell me how you chose your answer for the next question? IF AGREE: Can you say more about how reporting worker injuries/health concerns is encouraged?

Section J: Training on Workplace Health and Safety (scale: Strongly Disagree – Strongly Agree)

Draft Items	Interviewer Script, Probes, and Notes
In this [unit/nursing home/facility], providers and staff lack proper training in workforce/workplace safety practices and policies. (negatively worded)	Can you tell me how you chose your answer for the first question? [DO THEY CATCH NEGATIVE WORDING?]
In this [unit/nursing home/facility] providers and staff are adequately trained in workplace safety practices and policies.	Can you tell me how you chose your answer for the next question? What does it mean for providers and staff to be adequately trained…?
This [unit/nursing home/facility] has effective training programs to prevent workplace injuries.	Can you tell me how you chose your answer for the next question? IF AGREE: Can you say more about this program? Would you say it’s effective? How so?
In this [unit/nursing home/facility] providers and staff receive enough/adequate training on: the use of safe patient handling equipment and practices. the proper use of personal protective equipment (PPE). sharps safety protocols and policies. bullying and violence prevention protocols and policies.	Can you tell me how you chose your answer for the next question? IF ALL THE SAME: I noticed you marked the same answer for all of these – can you say more about that? IF DIFFERENT RESPONSES: I noticed you marked different answers for all of these – can you say more about that? Does your unit/facility provide this type of training? [IF NO] – Where do providers/staff get trained? Are providers trained differently than staff? how?

Section K: Overall Ratings on Workplace Safety

Draft Items	Interviewer Script, Probes, and Notes
Please give your [unit/nursing home/facility] an overall rating on workplace safety. Poor Fair Good Very good Excellent	Can you tell me how you chose your answer for the first question?
How effective is your organization at preventing injuries and managing the safety of providers and staff? Not at all effective Slightly effective Somewhat effective Very effective Extremely effective

CLOSING:

ADDRESS ANY WRITTEN COMMENTS IN SECTION R OR ANYTHING RELATED TO THE DEMOGRAPHIC QUESTIONS.

This survey uses a few different terms when asking about the safety of those who work in your [unit / nursing home / facility ] – for example ‘work place safety , work force safety, worker safety. Did you find any of these terms more or less easy to understand? Did you prefer one of these terms?

[FOR RS WHO DID NOT SELECT DK/DNA]: Now I have a general question about the survey. I noticed you didn’t select Does Not Apply or Don’t Know - the response option in the last column. Did you notice it?

Do you have any additional comments or feedback about the survey?

[IF TIME REMAINS] Thinking back to the earlier part of the survey that we did not talk about, do you recall if any of your answers in those sections were especially impacted, or hard to answer because of the COVID-19 pandemic?

Thank you very much for participating in this interview. Your comments have been helpful.

TURN OFF RECORDER

To show our appreciation for your time and help, we will send you a check for [$75/$100]. Please [confirm/tell me] your mailing address:

Mailing address:

We will send the check by FedEx and it should arrive within 10 business days – you do not have to be there to sign for it.

[NOTE: WE HAVE TO SUBMIT INFO TO ACCOUNTING BY COB MONDAY OR THURSDAY FOR TUESDAY AND FRIDAY PROCESSING - LET RESPONDENT KNOW APPROXIMATELY WHEN TO EXPECT CHECK.]

IMMEDIATELY AFTER THE INTERVIEW, ADD THE PARTICIPANT’S ADDRESS TO THE SPREADSHEET LINKED BELOW

\\westat.com\DFS\SOPS4\Optional Tasks\OT 10 - Workforce Safety & QDR\Workforce safety\Cognitive Testing\Recruitment Logistics\Workforce Safety-CogInterviews Participants_Reimbursement Tracking.xlsx

PLEASE LET VICKI GIVEN KNOW THAT THE INTERVIEW IS COMPLETE AND PROVIDE HER THE FOLLOWING INFORMATION:

PARTICIPANT ID#:

FIRST AND LAST NAME OF THE PARTICIPANT:

PARTICIPANT’S GENDER:

INDICATE IF THE PARTICIPANT IS A PHYSICIAN:

MAILING ADDRESS:

PHONE NUMBER (FOR FEDEX FORM):

INCENTIVE AMOUNT:

NAME OF LEAD INTERVIEWER