Form 023-20317 A1 (2) 023-20317 A1 (2) HRSA BHW Nurse Corps Participant Survey

		Updates needed based on Client review
Intro Language	The NURSE Corps is committed to continuous performance improvement. As part of this commitment, we are requesting feedback on your experiences with the NURSE Corps. This survey is hosted on a secure server and your responses will remain anonymous. This survey is authorized by Office of Management and Budget Control No. 1090-0007. This survey will take approximately 15 10 minutes to complete. Thank you in advance for your participation. Please click on the “Next” button below to begin.	change time to 10 minutes
Intro Questions
Number	Question
INTRO1	Through which program did you most recently join the NURSE Corps? 1. Scholarship Program 2. Loan Repayment Program 3. Loan Repayment Program – Nurse Faculty 4. None of the above [TERMINATE SURVEY]
INTRO2a	[IF INTRO1=1] Are you currently in nursing school? 1. Yes [DEFINE as GROUP 3 – Scholars in School] 2. No	Double check to make sure only Intro1=1 is getting this question
INTRO2b	[IF INTRO 2a = 2] Are you currently in residency? 1. Yes, RN Residency 2. Yes, NP Residency 3. No
INTRO2c	[IF INTRO2a=1] When do you expect to graduate? [NOTE: Drop down box for month and year selection]
INTRO2d	[IF INTRO2b=3] Do you plan on entering and completing a residency program? 1. Yes 2. No 3. I don’t know
INTRO3a	Please select your current professional health discipline. 1. Registered Nurse 2. Nurse Practitioner 3. Advanced Practice Registered Nurse 4. Nurse Faculty 5. Student-RN	Add Student-RN
INTRO3b	Please select your highest nursing degree or certification attained from the list below. 1. High School Diploma/GED 2. Nursing Diploma 3. Associate’s 4. Bachelor’s/Bachelor's Accelorated 5. Graduate Master’s 6. Post Master’s Certificate 7. Doctor of Nursing Practice 8. PhD	Add High School Diploma/GED
INTRO3c	[IF INTRO3b=1,2,3,4,5] Are you currently pursuing a higher degree or certification beyond a bachelor's degree? 1. Yes 2. No	add beyond a bachelor's degree
INTRO3d	[If INTRO3c=2] Do you plan to pursue a higher degree or certification? 1. Yes 2. No
INTRO3e	[IF INTRO3c=1 or INTRO3d=1] What degree or certification are you currently or planning to pursue? [CAPTURE RESPONSE]
INTRO3f	What is your specialty? 1. None – I don’t have a specialty 2. Adult 3. Family Practice 4. Pediatrics 5. Psychiatry 6. Women’s Health 7. Gerontology 8. Student-RN 9. Other, please specify [CAPTURE RESPONSE]	text change
Retention Questions
Number	Question
RET1	Have you completed your NURSE Corps service obligation? 1. Yes (Will be defined as Group 2 –Alumni) (Continue) 2. No (Will be defined as Group 1 – In Service) (SKIP TO RET3) 3. Graduated, but not yet serving [DEFINE as GROUP 3 – Scholars in School] [Skip to next section REC1]
RET2	[ONLY Group 2 (Alumni)] When did you complete your service obligation with the NURSE Corps? [NOTE: Drop down box for month and year selection]
RET3	[ONLY Group 1 (In Service)] Do you plan to remain at your current site after you have fulfilled your NURSE Corps service obligation? 1. Yes 2. No 3. Don’t know (SKIP TO RET14)	add /institution
RET4	[If RET3=YES] How long do you plan to remain at your current site? 1. Less than 1 year 2. 1 year to less than 2 years 3. 3 to 5 years 4. More than 5 years 5. Don’t know
RET5	[ONLY IF RET3=NO] What could your site do to encourage you to remain at your current site? (Rank up to 3 with 1 being the most influential.) 1. There’s nothing my site could do to change my decision to leave. (EXCLUSIVE) 2. Schedule flexibility 3. Salary increase 4. Change in site leadership 5. Provide recognition for service 6. Provide additional resources to do my job well 7. Other (Capture response)
RET6	[If Group 2 (Alumni)] Are you still employed at the critical shortage facility or teaching at the academic institution where you fulfilled your NURSE Corps service obligation? 1. Yes 2. No
RET7	[If RET6=YES] How long do you plan to remain at this site? 1. Less than 1 year 2. 1 year to less than 2 years 3. 3 to 5 years 4. More than 5 years 5. I don’t know
RET8	[ONLY IF RET6=YES] What influenced your decision to remain at your current site? [Rank up to 3, with 1 being the most influential] 1. Commitment to underserved communities 2. Salary 3. Ability to provide full scope of services 4. Experience at site 5. Balanced schedule/hours 6. Other, please specify [CAPTURE RESPONSE]
RET9	[ONLY IF RET6=NO] What could your site have done to encourage you to remain at your current site? (Rank up to 3 with 1 being the most influential.) 1. There’s nothing my site could do to change my decision to leave. (EXCLUSIVE) 2. Schedule flexibility 3. Salary increase 4. Change in site leadership 5. Provide recognition for service 6. Provide additional resources to do my job well 7. Other, please specify [CAPTURE RESPONSE]	Add institution
RET10	[ONLY IF RET6=NO] Did any of these external factors contribute to your decision to leave your site? [Rank up to 3, with 1 being the most influential] 1. Didn’t like the community and/or lifestyle 2. Distance from extended family/parents/siblings 3. Spouse employment opportunities 4. Length of commute 5. No external factors are contributing to my decision to leave. (EXCLUSIVE) 6. Other, please specify [CAPTURE RESPONSE]	Add institution
RET11	[If RET6=NO] Have you chosen to continue at a different critical shortage facility or academic institution since fulfilling your service obligation with the NURSE Corps Program? 1. Yes 2. No
RET12	Did you relocate to perform your service obligation? 1. Yes 2. No
RET13	(IF RET12 = yes)Why did you relocate to perform your service obligation? 1. No eligible facilities nearby 2. Local eligible facilities were not hiring 3. I wanted to relocate
RET14	[Group 1- In Service Clinicians]Please consider your previous training, including post graduate training. Using a 10-point scale on which 1 means Very poorly prepared and 10 means Very well prepared, how prepared were you to perform the following options at your site? 1. Evidence-based care 2. Patient-centered care 3. Team-based integrated care 4. Practice management and administration 5. Social determinants of health 6. Working in underserved community 7. Caring for medically complex/special needs patients 8. Population-based health 9. Quality improvement 10. Value-based care 11. Telehealth
RECRUITMENT [ASK ALL RESPONDENTS]
Number	Question
REC1	How did you learn about the NURSE Corps Program? (Select all that apply) [Allow for multiple responses] 1. Site/institution administrator or site/institution staff 2. Faculty at school/training programs 3. Colleague 4. Family member or friend 5. Current NURSE Corps member 6. Online research 7. Other (please specify) [CAPTURE RESPONSE]
REC2	[If REC1=1 and Intro2a NOT EQUAL TO 1] Did you seek employment at this site because of the NURSE Corps Loan Repayment Program? 1. Yes 2. No	This question should be skipped if Intro2a = 1
REC3	[Only Groups 1 & 2] How did you find out about the job where you completed your NURSE Corps service obligation? 1. I was already employed at the site 2. Internet search site 3. Referral from a friend or colleague 4. School or clinical rotation/residency program 5. Health Workforce Connector 6. HRSA Virtual Job Fair 7. Other, please specify [CAPTURE RESPONSE]
REC4	[Only if Intro2a NOT EQUAL TO 1] Would you be interested in serving as a clinical instructor/preceptor in exchange for loan repayment? 1. Yes 2. No	This question should be skipped if Intro2a = 1
CUSTOMER SERVICE PORTAL [ASK ALL RESPONDENTS]
PORT1	Have you used the Customer Service Portal in the last 12 months? The Customer Service Portal is a secured online account where NHSC/NURSE Corps members can conduct transactions, upload required documents, ask questions, and perform other online activities. 1. Yes 2. No (Skip to Next Section) 3. Don’t know (Skip to Next Section)	Remove NHSC as shown
PORT2	Please think about your overall experience using the Customer Service Portal in the last 12 months. Using a scale from 1 to 10, where 1 means poor and 10 means excellent, please rate. (Include N/A Option)
PORT2a	Ease of navigation
PORT2b	Ability to find the information needed
PORT2c	Ease of understanding the information communicated
PORT2d	Organization of the information provided
PORT2e	Usefulness of completing service requests through the Customer Service Portal
PORT2f	Timeliness of NHSC Nurse responses to your inquiry	Change to Nurse
PORT3	What additional feature, if any, would you like to see added to the Customer Service Portal? [CAPTURE RESPONSE]
CUSTOMER SERVICE [ASK ALL RESPONDENTS]
Number	Question
CUST1	Have you contacted the NURSE Corps during the past 12 months? 1. Yes 2. No (Skip to Next Section CUST5)
CUST2	In the past 12 months, through what means have you contacted the NURSE Corps? (Select all that apply) 1. Telephone (Customer Care Center) 2. E-mail (Direct Analyst Assistance) 3. Fax 4. Customer Service Portal 5. Facebook 6. Twitter 7. LinkedIn 8. Other, please specify [CAPTURE RESPONSE]
CUST3	What was the reason for your most recent contact with the NURSE Corps during the past 12 months? 1. Enrollment verification [Group 3] 2. Post graduate training verification/request [Group 3] 3. Ask a question [all] 4. Update my personal information [all] 5. Look at my service obligation end date [all] 6. Access my continuation application information [Group 1] 7. Request a transfer to a new site [Group 1] 8. Request to add a new site [Group 1] 9. Maternity/Paternity/Adoption leave request [Group 1 & 3] 10. Medical or non-medical suspension [Group 1 & 3] 11. Request a conversion from full-time to half-time service [Group 1] 12. Report unemployment [Group 1] 13. Request a default/waiver [Group 1] 14. Request assistance to find a new NHSC site [Group 1] 15. Complete in-service verification [Group 1] 16. Site visit Request [Group 3] 17. Relocation Request [Group 3] 18. View payment history [all] 19. Request leave of absence (personal/family/medical reasons) [Group 1&3] 20. Update contact information [all] 21. Update banking information [Group 1 and Group 3]	delete
CUST4	Thinking about your most recent contact with the NURSE Corps, and using a scale from 1 to 10, where 1 means not satisfied and 10 means very satisfied, please rate the following items
CUST4a	Ease of reaching a NURSE Corps representative
CUST4b	Courteousness of the NURSE Corps representative
CUST4c	Knowledge of the NURSE Corps representative
CUST4d	Timeliness of the representative’s response to your inquiry or concern
CUST4e	Usefulness of the information provided by the NURSE Corps representative
CUST4f	Overall professionalism of the NURSE Corps representative
CUST5	Please use this space for any additional information you would like to provide the NURSE Corps regarding ways we can improve the program. [CAPTURE RESPONSE]	Update so that all respondents get this question
MENTORING (ONLY GROUP 3 - IN SCHOOL)
Number	Question
MENT1	Do you participate in a NHSC Nurse mentoring program? 1. Yes 2. No (Skip to Next Section)	Change to Nurse
MENT2	How satisfied are you with your mentoring opportunities? Using a scale from 1 to 10, where 1 means poor and 10 means excellent, please rate.
SITE EXPERIENCE [ASK GROUP 1 AND 2]
Number	Question
SITE1	Using a scale from 1 to 10, where 1 means Poor and 10 means Excellent, please rate your overall experience at the site/institution where you have fulfilled/are fulfilling your service obligation with the NURSE Corps. [CAPTURE RESPONSE]	Add institution
SITE2	What type of support did your site provide that was useful? (Select all that apply) [Allow for multiple responses] 1. Peer-to-peer communication 2. Conferences 3. Network opportunities 4. Mentoring 5. Continuing education 6. Other, please specify [CAPTURE RESPONSE]
SITE3	Does your organization have a need for NURSE Corps participants to split their time across multiple sites within the same network? 1. Yes 2. No 3. Unsure
SITE4	Using a scale from 1 to 10, where 1 means Poor and 10 means Excellent, please rate your overall experience at the academic institution/site where you have fulfilled/are fulfilling your service obligation with the NURSE Corps. [CAPTURE RESPONSE]	add site
OUTCOME MEASURES [ASK GROUP 1]
Number	Question
OUT1	[ASK ONLY OF GROUP 1] On a scale from 1 to 10 where 1 means Not at All Likely and 10 means Very Likely, how likely are you to remain at your NURSE Corps site after your service obligation is complete? [CAPTURE RESPONSE]
OUT2	[ASK ONLY OF GROUP 1] On a scale from 1 to 10 where 1 means Not at All Likely and 10 means Very Likely, how likely are you to continue to provide health services in a critical shortage facility after your service obligation is completed? [CAPTURE RESPONSE]
OUT3	(If OUT2>=6) What has contributed to the likelihood that you will continue to serve in a critical shortage facility after your service obligation is complete? (Rank up to 3, with 1 being the most influential) 1. Salary 2. Opportunities for advancement 3. Experience at site 4. Site operation/direction closely aligned with my personal goals 5. Balanced schedule/hours 6. Availability of resources to do my job well 7. Commitment to underserved communities 8. Other, please specify [CAPTURE RESPONSE]	Check on how this works in link
OUT4	(If OUT2<6) What would increase your likelihood to continue to serve in a critical shortage facility after your service obligation is complete? (Rank up to 3, with 1 being the most influential) 1. Salary 2. Opportunities for advancement 3. Experience at site 4. Site operation/direction closely aligned with my personal goals 5. Balanced schedule/hours 6. Availability of resources to do my job well 7. Commitment to underserved communities 8. Other, please specify [CAPTURE RESPONSE]	Client's request: Can we capture the “other” option in the list vs. a separate follow up question: What has contributed to the likelihood that you will continue to serve in a critical shortage facility after your service obligation is complete? Rank up to 3, with 1 being the most influential.”
OUT5	On a scale from 1 to 10 where 1 means not at all likely and 10 means very likely, how likely are you to recommend the NURSE Corps to someone else?
DEMOGRAPHICS
Number	Question
DEM1	What is your gender? 1. Male 2. Female 3. Transgender Male 4. Transgender Female 5. Prefer not to say
DEM2	What is your year of birth? [Scroll for year]
DEM3	What is your ethnicity? 1. Hispanic or Latino 2. Not Hispanic or Latino 3. Prefer not to say
DEM4	What is your race? (Select all that apply) 1. American Indian or Alaskan Native 2. Asian 3. Black or African American 4. Native Hawaiian or Other Pacific Islander 5. White 6. Other, please specify 7. Prefer not to say
DEM5	(Groups 1 and 2 only) Are you currently practicing, or have you practiced, in an underserved area that is within 100 miles of where you grew up/where you concider home? 1. Yes 2. No
DEM6	(Groups 1 and 2) Are you currently practicing, or have you practiced, in an underserved area that is within 100 miles of where you completed your clinical training? 1. Yes 2. No
DEM7	(Group 3) Are you currently attending nursing school within 100 miles of where you grew up/where you consider home? 1. Yes 2. No
DEM8	(Group 3) Do you plan to practice within 100 miles of where you completed your health professions training? 1. Yes 2. No 3. Don’t Know
DEM9	(Group 3 and DEM7=NO) Do you plan to practice within 100 miles of where you grew up/where you consider home? 1. Yes 2. No 3. Don't Know
DEM10	(Group 1 ONLY and if INTRO1= 1 or 2) Does the NHSC Nurse site where you are currently working use any form of telehealth? 1. Yes 2. No [SKIP to DEM18]	Change to Nurse
DEM11	(Group 1 ONLY or INTRO1= 1 or 2)What type of Telehealth capabilities does your site have? [MULTISELECT] 1. Video conferencing 2. Store and forward video 3. Remote patient monitoring 4. Mobile health (mhealth) 4. I don’t know 5. Other [CAPTURE RESPONSE]
DEM12	(Group 1 ONLY and if INTRO1= 1 or 2) Is your clinic… 1. The originating site (where the patient is located) 2. The distant site (where the clinician is located) 3. Both the originating site and distant site
DEM13	(Group 1 ONLY or INTRO1= 1 or 2) Do you use any form of telehealth to provide care in your practice? 1. Yes 2. No
DEM14	(Group 1 ONLY and if INTRO1= 1 or 2) [If DEM10=YES, DEM12=BOTH and DEM13=Yes] Are you… 1. the clinician at the distant site providing the care 2. the clinician at the originating site assisting with the care 3. other [CAPTURE RESPONSE]
DEM15	(Group 1 ONLY and if INTRO1= 1 or 2) [If DEM13=YES] What percentage of your clinical practice is spent providing telehealth services? a) <10% b) 10-25% c) 26-49% d) 50%> e) I don’t know
DEM16	(Group 1 ONLY and if INTRO1= 1 or 2)What would you consider to be the optimal percentage of time spent providing telehealth services, assuming you had the opportunity to do so? 1. 0% 2. 25% 3. 50% 4. 75% 5. 100% 6. Other [CAPTURE RESPONSE]
DEM17	[If DEM13=NO] Why don’t you use telehealth in your clinical practice? [CAPTURE RESPONSE]
DEM18	[If DEM10=NO] Why doesn’t your site use some form of telehealth? (Select all that apply) 1. Costs too high 2. Lack technical knowledge 3. Resistance among staff 4. Licensing barriers 5. Connectivity/bandwidth 6. I don’t know 7. No demand for telehealth 8. Other [CAPTURE RESPONSE]
DEM19	(Group 1) From the list below, please select the option that best describes where you currently practice: 1. Hospital – Critical Access Hospital 2. Hospital – Disproportionate Share Hospital 3. Hospital – Public Hospital 4. Hospital – Private Hospital 5. Ambulatory Care – Ambulatory Surgical Center 6. Ambulatory Care – Federally Qualified Health Center (FQHC) or Look-Alike 7. Ambulatory Care – American Indian Health Facility 8. Ambulatory Care – Native Hawaiian Health Center 9. Ambulatory Care – Nurse Managed Health Clinic/Center 10. Ambulatory Care – Rural Health Clinic 11. Ambulatory Care – Urgent Care Center 12. Public Health (State or Local Public Health or Human Service Department) 13. Long Term Care – End Stage Renal Disease Dialysis Centers 14. Long Term Care – Home Health Agency 15. Long Term Care – Hospice Program 16. Long Term Care – Residential Nursing Home 17. Long Term Care – Skilled Nursing Facility 18. Mental Health – Certified Community Behavioral Health Clinic (CCBHC) 19. Public Academic Institution/Nursing School 20. Private Academic Institution/Nursing School 22. No Longer Providing Direct Patient Care 23. Private Practice/Solo Group
DEM20	(Group 2 only) From the list below, please select the site that best describes where you were working when you finished your service obligation. 1. Hospital – Critical Access Hospital 2. Hospital – Disproportionate Share Hospital 3. Hospital – Public Hospital 4. Hospital – Private Hospital 5. Ambulatory Care – Ambulatory Surgical Center 6. Ambulatory Care – Federally Qualified Health Center (FQHC) or Look-Alike 7. Ambulatory Care – Indian Health Service Health Center 8. Ambulatory Care – Native Hawaiian Health Center 9. Ambulatory Care – Nurse Managed Health Clinic/Center 10. Ambulatory Care – Rural Health Clinic 11. Ambulatory Care – Urgent Care Center 12. Public Health (State or Local Public Health or Human Service Department) 13. Long Term Care – End Stage Renal Disease Dialysis Centers 14. Long Term Care – Home Health Agency 15. Long Term Care – Hospice Program 16. Long Term Care – Residential Nursing Home 17. Long Term Care – Skilled Nursing Facility 18. Mental Health – Certified Community Behavioral Health Clinic (CCBHC) 19. Public Academic Institution/Nursing School 20. Private Academic Institution/Nursing School 21. Other [CAPTURE]
DEM21	(Group 2 only) Where are you practicing now? Please select from the list below. 1. Hospital – Critical Access Hospital 2. Hospital – Disproportionate Share Hospital 3. Hospital – Public Hospital 4. Hospital – Private Hospital 5. Ambulatory Care – Ambulatory Surgical Center 6. Ambulatory Care – Federally Qualified Health Center (FQHC) or Look-Alike 7. Ambulatory Care – American Indian Health Facility 8. Ambulatory Care – Native Hawaiian Health Center 9. Ambulatory Care – Nurse Managed Health Clinic/Center 10. Ambulatory Care – Rural Health Clinic 11. Ambulatory Care – Urgent Care Center 12. Public Health (State or Local Public Health or Human Service Department) 13. Long Term Care – End Stage Renal Disease Dialysis Centers 14. Long Term Care – Home Health Agency 15. Long Term Care – Hospice Program 16. Long Term Care – Residential Nursing Home 17. Long Term Care – Skilled Nursing Facility 18. Mental Health – Certified Community Behavioral Health Clinic (CCBHC) 19. Public Academic Institution/Nursing School 20. Private Academic Institution/Nursing School 21. No Longer Providing Direct Patient Care
DEM23	[Groups 1 & 2] On average, how many patients do you see per day? [Free response – validate that entry is whole number (0 allowed)]
DEM24	[Groups 1 & 2 – ONLY IF THEY SELECTED MENTAL AND BEHAVIORAL HEALTH DISCIPLINE] Does your site provide mental and behavioral health services? 1. Yes 2. No
DEM25	(Groups 1 and 2) Please list the ZIP code of the site where you practice. If you practice at more than one site, please list the ZIP code for the site where you spend the majority of your time practicing. (Capture numerical response)
DEM26	(Group 3) From the drop-down box below, please select the state where you are currently attending nursing school. [CAPTURE]