Form 1 Health Providers Screening Instrument

OMB No. 0990-0281

Exp. Date 09/30/2021

Screening Instrument for Health Care Providers (HCPs)

Health Care Providers – Interview Groups
Medical Specialty	Primary care physicians (MDs, DOs)	Non-physicians (NPs, PAs)	Total HCPs
Internal Medicine/Family Practice	N = 4	N = 4	N = 8
Obstetrics and Gynecology (OB/GYN)	N = 4	N = 4	N = 8
Total	N = 8	N = 8	N = 16

Section I: Screening

1. What is your age?

___ Age 25–65 years (RECORD AND CONTINUE)

___ Age <25 years or >65 years (RECORD; THANK AND TERMINATE)

___ Don’t know (RECORD; THANK AND TERMINATE)

2. What is your medical specialty?

___ Family medicine or internal medicine physician (MDs, DOs) in a primary care setting (RECORD AND CONTINUE)

___ Obstetrics and gynecology (OB/GYN) physician (MDs, DOs) (RECORD AND CONTINUE)

___ Physician assistant/nurse practitioner in a primary care setting (RECORD AND CONTINUE)

___ Physician assistant/nurse practitioner in an OB/GYN setting (RECORD AND CONTINUE)

___ Other (TERMINATE)

3. How many years have you been in practice?

___ <1 year (RECORD; THANK AND TERMINATE)

___ 1–5 years (RECORD AND CONTINUE)

___ 6–10 years (RECORD AND CONTINUE)

___ >10 years (RECORD AND CONTINUE)

4. Do you routinely ask women about their military service or veteran status?

___ Yes (RECORD AND CONTINUE to 5)

___ No (RECORD; CONTINUE TO 4b)

4b. For what reasons do you not assess military or veteran status among your patients?

___ Not relevant for my patient population (RECORD; THANK AND TERMINATE)

___ Not a routine question in my practice (RECORD; THANK AND TERMINATE)

___ Military/veteran status is unnecessary information (RECORD; THANK AND TERMINATE)

___ Other, please describe (RECORD; THANK AND TERMINATE)

_______________

5. Are you or your practice affiliated with the Veterans Health Administration (VHA) or Military Health System (MHS)?

___ Yes (RECORD; THANK AND TERMINATE)

___ No (RECORD AND CONTINUE)

6. About how many hours per week do you see patients?

___ More than 30 (RECORD AND CONTINUE)

___ Less than 30 (RECORD; THANK AND TERMINATE)

7. Approximately what percentage of your patient population is women ages 18–64?

___ 40% or more (RECORD AND CONTINUE)

___ Less than 40% (RECORD; THANK AND TERMINATE)

8. What city and state do you practice in? (RECRUIT MIX OF GEOGRAPHIC LOCATIONS, INCLUDING TEXAS, CALIFORNIA, FLORIDA, VIRGINIA, GEORGIA, NORTH CAROLINA, OHIO, PENNSYLVANIA, NEW YORK, WASHINGTON, COLORADO) ___________________ (RECORD AND CONTINUE)

9. Which of the following best describes your practice location? (RECRUIT MIX; READ ALL RESPONSE OPTIONS)

___ Rural (RECORD AND CONTINUE)

___ Suburban (RECORD AND CONTINUE)

___ Urban (RECORD AND CONTINUE)

10. How would you describe your practice setting/type? (RECRUIT MIX; READ ALL RESPONSE OPTIONS)

___ Academic/teaching facility (RECORD AND CONTINUE)

___ Community health setting (RECORD AND CONTINUE)

___ Group practice (RECORD AND CONTINUE)

___ Private practice (RECORD AND CONTINUE)

___ Federally Qualified Health Center (RECORD AND CONTINUE; RECRUIT AT LEAST TWO)

___ Other (RECORD; THANK AND TERMINATE)

11. Which of the following best describes your ethnicity? (READ ALL RESPONSE OPTIONS;

___ Hispanic or Latino (RECORD AND CONTINUE)

___ Not Hispanic or Latino (RECORD AND CONTINUE)

12. Which of the following best describes your race? Please select one or more as applicable. (READ ALL RESPONSE OPTIONS;

___ White (RECORD AND CONTINUE)

___ Black or African-American (RECORD AND CONTINUE)

___ American Indian or Alaska Native (RECORD AND CONTINUE)

___ Asian (RECORD AND CONTINUE)

___ Native Hawaiian or Other Pacific Islander (RECORD AND CONTINUE)

Section II: Informed Consent Form

Good news, you are eligible to participate in this project! I’d like to go through the consent form now to make sure that I cover all aspects of the project and give you the opportunity to ask any questions you may have. Please feel free to interrupt me at any time if you have any questions.

Hager Sharp, an independent communications firm, is inviting you to participate in a 60-minute interview to learn about your experiences caring for active duty and veteran women as a non-VHA/non-MHS health care provider. To decide if you want to be a part of this project, you should know enough about it to make an informed decision. This consent form goes over the project’s purpose, what is involved, and possible risks and benefits. Once you understand the project, you will be asked if you wish to participate; if so, we will record your verbal consent to participate.

Purpose of the Project

The purpose of this project is to explore providers' perception of the healthcare needs of active duty and veteran women and their experiences providing care for this population. We will ask you questions about your facilitators for and barriers to providing care, as well as your opinions on the informational and training needs of you and other healthcare providers. This project is being conducted by the U.S. Department of Health and Human Services (HHS) Office on Women’s Health (OWH). Representatives from Hager Sharp will administer the interviews on behalf of OWH.

Description of Procedures

If you agree to participate in this project, you will be provided with dial-in information and instructions to take part in a telephone interview. To thank you for your time, you will receive a [$180 for physicians; $150 for non-physicians] cash compensation.

Risks

The interviewer will ask you about your experiences, facilitators for, and barriers to caring for active duty and veteran women, as well as your opinions on the resources available or needed by healthcare providers on this population. You may choose to skip any question for any reason.

Benefits

There are no direct benefits to you as a participant in this project. However, your participation will help OWH understand healthcare providers’ experiences caring for active duty and veteran women. Hearing from you may help promote awareness of active duty and veteran women-related issues among providers and help develop resources to improve healthcare training and delivery.

Confidentiality and Privacy

The information you give us will be kept private to the extent required by law. The personal information and identifiable information recorded to schedule the interview will be kept with Hager Sharp. To protect your privacy, we will keep your interview transcript under a code number instead of your name. The project staff will keep a link to you and your coded information that will be secured and available only to a limited number of staff. We will keep your records in locked files, and only project staff will be allowed to look at them. Your name and other facts that point to you (such as your email address and phone number) will never appear in any report or presentation.

Voluntary Participation and Withdrawal

You are free to choose not to take part in this project. You may stop participating at any time, for any reason. If you have questions about this project, if you would like to withdraw from this project, or if you think you have been harmed by this project, please contact Carolin Serafini at 202-706-7461 or [email protected].

Questions

We have used some technical terms in this form. Please feel free to ask about anything you don't understand. Please do consider this project and consent form carefully – as long as you feel is necessary – before you make a decision.

Do you have any questions?

Would you like to participate in a telephone interview? (VERBAL CONSENT)

___ Yes (ON FACESHEET RECORD YES, CONSENT GIVEN, DATE AND INITIAL)

___ No, Okay, thank you for your time today. (STOP HERE)

VERBAL CONSENT
Record after reading through dialogue above.	___ Yes ___ No Date: Initials:

CONFIRM NAME SPELLING, EMAIL, AND PHONE

• Great! Now I just have to get your contact information. Could you please spell your first and last name? (Record below in “Participant PREFERRED CONTACT INFORMATION”)

• What is the best number where you can be reached? (Record below in “Participant PREFERRED CONTACT INFORMATION”)

• What is the best email address where you can be reached? As a reminder, this needs to be an email address that you use frequently. (Record below in “Participant PREFERRED CONTACT INFORMATION”)

• How would you like us to contact you in the event we need to reach you (email or phone)? (Record below in “Participant PREFERRED CONTACT INFORMATION”)

  • [If phone] What is the best day and/or time to reach you via phone? (Record below in “Participant PREFERRED CONTACT INFORMATION”)

Participant Preferred COntact Information
PARTICIPANT NAME:
LANDLINE:	CELL:
EMAIL (must be an email address that is used frequently):
Best time and way to reach:

Section III: Scheduling Interview

The final step is to get you scheduled for the interview. [REFER RESPONDENT TO ONLINE SCHEDULER}

Prior to the interview, you will be sent (via your preferred contact information) the dial-in information and instructions for how to join the telephone interview. If after we hang up, if you have a question about the focus group or decide you can’t participate, please contact [INSERT RECRUITER NAME AND CONTACT INFO].

Public reporting burden of this collection of information is estimated to average 3 minutes per response, including the 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 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 Office of the Chief Information Officer, Department of Health and Human Services, Sherrette Funn, [email protected] or (202) 795-7714; ATTN: PRA (xxxx-xxxx).