0920-20PT Recruitment Screener_Physician

ATTACHMENT 1b: RECRUITMENT SCREENER

OMB No. 0920-0572

Exp. Date 08/31/2021

Paperwork Reduction Act Statement: The public reporting burden for this information collection has been estimated to average 8 minutes per response. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA 0920-0572.

A 60-Minute Interview With

Physicians Serving Patients

At Risk for Tuberculosis*

[*NOTE TO RECRUITER: Do NOT reveal to potential interview participants that the topic of this study is tuberculosis. We do NOT want any participants to do any personal research that may otherwise lead to altered responses regarding their knowledge of and experience with tuberculosis before the focus group discussion.]

Hello. My name is ________ and I’m calling from _________, an independent communications firm.

You indicated that you are interested in participating in a one-on-one conversation, conducted virtually, to discuss your practices and opinions regarding disease prevention, screening, and identification. [DO NOT DISCLOSE THE EXACT TOPIC OF DISCUSSION BEFORE THE INTERVIEW.] The discussion will last approximately 1 hour. The sole sponsor of this activity is Centers for Disease Control and Prevention (CDC).

I have a few questions to start. To maintain participants’ confidentiality, we will use first names only during the discussion and your name will not be used in any study materials. CDC is not interested in any of your personal information. We will be asking you a few questions to ensure we are recruiting a mix of people, but the information will not be associated with your specific name.

IF TERMINATED DURING SCREENING PROCESS READ: I’m sorry, we already have enough individuals in that category. Thank you very much for your time.

INTERVIEWER INSTRUCTION: If individual expresses concern at any point during the screening process, please note their concern and reassure them appropriately. Remind them that their answers and participation will be completely confidential.

Eligibility Questions

[RECRUIT FOUR INTERVIEWS PER CITY, FOR A TOTAL OF 12 PARTICIPANTS.]

1. RECORD SEX:

Male		RECRUIT 2-3 MALES AND 1-2 FEMALES PER LOCATION
Female	

2. What is your age? [RECORD EXACT AGE:________; DO NOT READ LIST]

39 or younger		RECRUIT A MIX
40-49	
50-59	
60 or older		LIMIT TO 1 PER LOCATION

3. In what town or city do you reside? [RECORD CITY: ______] MUST RESIDE WITHIN THE NEW YORK CITY, LOS ANGELES OR HOUSTON DMAS

4. To confirm, are you a board certified, practicing MD or DO?

MD (Medical Doctor)	
DO (Doctor of Osteopathic Medicine)		THANK AND TERMINATE

5. What is your medical specialty? [READ LIST]

Family Physician		RECRUIT A MIX
General Internist	
General Practitioner	
Med-Peds (Combined Internal Medicine & Pediatrics)	
Hospitalist		THANK AND TERMINATE
Other (Please Specify)		CONSULT WITH KRC. HOLD AND RECORD

6. Is your primary responsibility direct patient care?

Yes	
No		THANK AND TERMINATE

7. On average, how many hours per week do you spend in direct patient care? [RECORD ACTUAL HOURS: _______]

19 hours a week or less		THANK AND TERMINATE
20 to 39 hours a week	
40 or more hours per week	

8. In your practice, approximately what percent of your time is dedicated to adult care? [RECORD EXACT PERCENTAGE: _______]

50% or more	
Less than 50%		THANK AND TERMINATE

9. Are your patients primarily comprised of those in a hospital, rehabilitation facility, assisted living or nursing home?

Yes		THANK AND TERMINATE
No	

10. Do you have a subspecialty? [IF YES] What is it? [RECORD]

Yes		RECORD: TERMINATE if Gerontology
No	

11. [IF YES:] What percent of your practice is dedicated to your subspecialty? _______ RECORD; MUST BE LESS THAN 50%; IF 50% OR MORE, THANK AND TERMINATE

12. What year did you complete medical school? [RECORD:] ______________________

13. What was the name of your medical school where you received your training? [RECORD:]______________________

[VERIFY WHETHER THE MEDICAL SCHOOL IS IN THE UNITED STATES]

In the US: ___________________	
Outside the US: _______________		THANK AND TERMINATE

14. In approximately what year did you complete your (first) residency that is associated with your role as a primary care physician? [RECORD:] ______________

If year is 2015 or later		THANK AND TERMINATE
Between 1980 and 2014	
If year is 1979 or earlier		LIMIT TO 1 PER LOCATION

15. Is the primary practice setting you work in a…? [READ LIST]

State or local government agency such as Public Health Department		THANK AND TERMINATE
Private community-based health center		RECRUIT A MIX
Federally Qualified Health Center (FQHC)	
Private practice	
Academic Institution		THANK AND TERMINATE
Private Corporation such as Pharmaceutical Companies, Research Lab		THANK AND TERMINATE
None of the above		THANK AND TERMINATE

16. Which best describes your practice setting?

Solo practice	
Single specialty group practice	
Multi-specialty group practice	
Staff Model Health Maintenance Organization or HMO		LIMIT TO ONE
Other model HMO, Managed Care Organization	
Network managed care systems such as PPOs	
Mixed model practice	
Hospital-based practice		THANK AND TERMINATE
Indigent care facility	
Publically managed and funded clinic	
Locum Tenens or temporary physician employment		THANK AND TERMINATE
Other: SPECIFY:		CONSULT WITH KRC. HOLD AND RECORD

17. Do you serve any of the following patient populations at your practice? [READ LIST]

Indians born in India	
Filipinos born in the Philippines	
Chinese born in mainland China (Mandarin speaking)	
Vietnamese born in Vietnam	
Mexican born in Mexico		THANK AND TERMINATE IF SERVING MEXICAN AND/OR GUATEMALAN ONLY
Guatemalan born in Guatemala	
None		THANK AND TERMINATE

18. You serve [INSERT LIST OF GROUP(S) FROM Q17]. Altogether, approximately how many [INSERT LIST OF GROUP(S) FROM Q17] patients combined do you personally serve each week? [RECORD EXACT NUMBER: _______]

19 or fewer		THANK AND TERMINATE
20-29	
30-39	
40 or more	

19. Does your practice communicate with your patients in other languages besides English? This could include language services, but also patient materials.

Yes	
No		THANK AND TERMINATE

20. Does your practice communicate with your patients in any of the following languages?

    Hindi	
    Tagalog	
    Mandarin	
    Vietnamese	
    Spanish	
    Other: SPECIFY	
    None		THANK AND TERMINATE

21. Specifically, which communication services does your practice offer?

Bilingual or multilingual healthcare providers	
Interpreters	
Language lines	
In-language patient education materials	
Other: SPECIFY	
None		THANK AND TERMINATE

22. Have any of your patients been diagnosed with any of the following conditions in the last year?

Hepatitis A, B, or C	
HIV/AIDS	
Tuberculosis Disease or Latent Tuberculosis Infection	
Diabetes	

23. Are you Hispanic, Latino/a, or Spanish origin?

No, not of Hispanic, Latino/a, or Spanish origin	
Yes, Mexican American, Chicano/a	
Yes, Puerto Rican	
Yes, Cuban	
Yes, another Hispanic, Latino/a or Spanish origin	

24. [IF NO TO Q23]: What is your race? [READ LIST] RECRUIT 1 NON-WHITE

White	
Black or African American	
American Indian or Alaska Native	
Asian Indian	
Chinese	
Filipino	
Japanese	
Korean	
Vietnamese	
Other Asian	
Native Hawaiian	
Guamanian or Chamorro	
Samoan	
Other Pacific Islander	

25. How many times within the past three months have you participated in a focus group or one-on-one interview related to your professional expertise? [DON’T READ RESPONSE CATEGORY]

None	
1 or more		THANK AND TERMINATE

INVITATION

Thank you for answering all of my questions. As I mentioned, we respect your privacy and understand this information is confidential, and we will not disclose this information to anyone. We asked these questions because we want to speak with a wide variety of people who can review important information and provide their feedback. Based on your answers to the questions, we would like to invite you to participate in a one-hour virtual interview.

You will receive $75 as a token of appreciate for your participation, which will be provided to you after you complete the interview.

All of your feedback will be anonymous and confidential, reported in the aggregate only, never in association with your name or identity. To make sure we capture your remarks accurately, we will audio-record the interview. The purpose of the audio recording is to make sure we report accurately, but without any personally identifying information.

Is this discussion something you are interested in and comfortable with?

Yes		SHARE DATE AND TIME OF INTERVIEW
No		THANK AND TERMINATE

Additionally, the interview is virtual, meaning that you can participate from the comfort of your home, but you will need to be in front of a computer with internet access so you can review information, as well as on a telephone. Someone will call you before the group to make sure all the technology needed for the discussion is working properly.

Is this something you are interested in and comfortable with?

Yes	
No		THANK AND TERMINATE

FOR SCHEDULED PARTICIPANTS:

The discussion has been scheduled on Month Day, 2019 at X:XX a.m./p.m. -- X:XX a.m./p.m. Before your scheduled session, we will send you a confirmation with all the required logistical and technology information. And, we will call you the day before the interview to make sure that your computer and phone are working properly.

If you wear reading glasses or use a hearing aid, please remember to bring those to the interview. Some of our activities will involve reading.

If you must cancel, please let us know immediately, so we can find someone to take your place. My name is ___________ and you can reach me at _____________.