2 Medical office information survey

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

Site-Level Data File Specifications

AHRQ Medical Office Survey on Patient Safety Culture

Use these instructions if you are submitting data from multiple medical offices all at the same time.

INSTRUCTIONS:

Step 1: Site-level data must be in Excel format (.xls, .xlsx).

Step 2: Include a header row with the variable name for each column.

Please include all variable names from the table below and ensure that each one is entered in the correct column. Failure to do so will result in delays in processing your data.

Step 3: Site IDs must match IDs in respondent-level data file.

Please enter a unique Site ID for each medical office. Make sure that each medical office’s Site ID matches its Site ID in your respondent-level data file. This step is crucial for linking site-level and respondent-level data.

Step 4: File must contain one record for each medical office.

Enter each medical office in a separate row, including all required variables from the table below.

Definition of a Medical Office:

• A medical office is defined as an outpatient facility in a specific location.

• Each medical office located in a building containing multiple medical offices is considered a separate medical office.

• Providers in a single medical office should share administrative and clinical support staff. If they do not share these staff, the offices should be considered separate offices.

Column	Variable Name	Variable Label	Type			Details/Comments
Column A*	SiteID	Site ID		Numeric	Unique Site ID matching respondent-level data file.
Column B*	SiteName	Site Name		Character	Please use a unique name for each medical office.
Column C*	Address1	Street Address 1		Character
Column D	Address2	Street Address 2		Character
Column E*	City	City		Character
Column F*	State	State		Character	2-character State abbreviation
Column G*	ZipCode	Zip Code		Character	5-digit zip code (include leading zeroes)
Column H	ZipPlusFour	Zip Code +4		Numeric	4-digit zip code extension

Public reporting burden for this collection of information is estimated to average 3 minutes per response, the estimated time required to complete the survey. 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.

You must enter the name, phone number, and email of the contact person at each medical office.
Column I*	Contact_First	Contact First Name		Character
Column J*	Contact_Last	Contact Last Name		Character
Column K*	Contact_Phone	Contact Phone #		Numeric	10-digit phone number with no spaces or dashes
Column L	Contact_Ext	Contact Extension		Numeric	Phone number extension
Column M*	Contact_Email	Contact Email Address		Character
*Indicates required information for each medical office.
Column N*	Ownership	Which best describes the majority ownership of this medical office/practice?	Numeric (1-6)			Provider(s) and/or Physician(s) Hospital or Health System University or Academic Medical Center Community Health Center Federal, state, or local government Other
Column O*	Denominator	Total number of employees asked to complete the survey	Numeric			Must be 5 or more.
Column P*	SurveyMode	What was the mode used to administer the survey?	Numeric (1-4)			Paper Web Mixed mode (paper & web) Other
Column Q*	EndMonth	End Month of Data Collection Completion	Numeric (1-12)			Month of data collection completion
Column R*	EndYear	End Year of Data Collection Completion	Numeric			Year of data collection completion (YYYY)
Column S*	Num_providers_wk	What is the total number of providers (MDs, DOs, PAs, NPs,) working in this medical office location during a typical week?	Numeric			Enter total number of providers working during a typical week (across all providers)
Column T*	Type_practice	Which of the following best describes the type of practice at this office location?	Numeric (1-2)			Single specialty Multispecialty

	If single specialty ONLY, select one specialty from the list of specialties in Column U.
	*Indicates required information for each medical office.
Column U**		Specialty	What is the specialty of the provider(s) at this office location?		Allergy/Immunology Anesthesiology Cardiology Child & Adolescent Psychiatry Dermatology Diagnostic Radiology Emergency Medicine Endocrinology/ Metabolism Family Practice/Family Medicine Forensic Pathology Gastroenterology General Practice General Preventive Medicine General Surgery Geriatrics Hematology/Oncology Internal Medicine Medical Genetics Nephrology Neurology Nuclear Medicine OB/GYN or GYN Ophthalmology Orthopedics Otolaryngology Pathology – Anatomic/Clinical Pediatrics Physical Medicine & Rehabilitation Psychiatry Public Health & Rehabilitation Pulmonary Medicine Radiology Rheumatology Surgery (All) Urology Vascular Medicine Other specialty

*Indicates required information for each medical office.

** Required only for single specialty medical offices.

MOS-1015 4