0920-0572 HCP Screener Online Survey

OMB No. 0920-0572

Expiration Date 08/31/2021

Brand Concept and Message Testing for Diabetes Self-Management Education and Support (DSMES) Services:

Recruitment Screener for Health Care Providers

Introduction

We are seeking providers interested in participating in an online survey. We are conducting this work on behalf of the U.S. Centers for Disease Control and Prevention, also known as CDC. If you qualify and complete the survey, you will receive $[MD: 45, ENDOCRINOLOGIST: 65; OTHER PROVIDER TYPE: 45] as a token of appreciation. To see if you qualify to take a survey about diabetes education, please answer the following questions. These questions will take less than 5 minutes to answer and your answers will be confidential.

• I agree to answer screening questions Continue

• Do not agree to answer screening questions Terminate

Public reporting burden of this collection of information is estimated to average 5 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 CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0572). 

Screening Questions

1. What is your gender?

• Male Continue

• Female Continue

• Other Continue

2. Are you a…?

• Physician/MD/DO Continue

• Nurse Practitioner Continue

• Registered Nurse Terminate

• Advanced Practice Registered Nurse Continue

• Physician Assistant Continue

• Other [specify] Terminate

3. [For Physicians only] What is your medical specialty?

• General Practice/General Medicine/Internal Medicine/Family Medicine Continue

• Endocrinology Continue

• Other Terminate

4. [for NPs, APRNs and PAs only] Which of the following medical specialty areas do you work in?

• Endocrinology Continue

• Internal Medicine Continue

• General/Family Medicine Continue

• Other Terminate

5. Are you a Certified Diabetes Educator, a part of the Fellows Program of the American Association of Diabetes Educators, or have a Board Certified-Advanced Diabetes Management credential (BC-ADM)?

• Yes Terminate

• No Continue

6. What type of practice/health system(s) do you work in?

• Solo or two-physician practice (independent) Continue

• Physician-owned group practice (independent) Continue

• Health care system (employed physician practice) (e.g. HMO, medical school, NGO hospital or clinic, federal/state/local hospital or clinic, community health center).…………………………………. Continue

• Other: Terminate

7. How many years have you been in practice?

• Under 1 year Terminate

• 2-10 years Continue

• 11+ years Continue

8. Are most of your patients 18 years old and older?

• Yes Continue

• No Terminate

9. Roughly what percentage of the adult patients you see have type 1 or type 2 diabetes?

• Less than 20% Terminate

• 20% or more Continue

10. Do you serve adult patients with type 1 diabetes?

• Yes Continue

• No Continue

11. Now I’d like to ask you some questions about your referral practices. Do you refer your patients with diabetes to a diabetes educator or team of professionals who provide education and support in an individual or group setting?

[Do NOT include people that only refer to an endocrinologist, UNLESS endocrinologist practice offers DSMES. We are NOT interested in referrals to endocrinologists solely for medical treatment/monitoring—must be about education as well]

• Yes, I refer to diabetes self-management and support services (DSMES) Continue

• No Continue

12. [IF YES TO Q11] Do you know if the diabetes education and support you refer your patients to is accredited or recognized by the American Diabetes Association (ADA) or Association of Diabetes Care and Education Specialists (ADCES, formerly known as American Association of Diabetes Educators or AADE)?

• Yes, it is/they are accredited/recognized Continue

• No, it is/they are NOT accredited/recognized Continue

• Don’t know Continue

13. [IF YES TO Q11] Is this diabetes education program or service within your practice, within your health care system/organization, part of an external organization, or offered online? [select all that apply]

• Within my practice Continue

• Within my health care organization Continue

• External organization Continue

• Online Continue

14. Do you work in a rural, urban, or suburban area?

• Rural Continue

• Urban Continue

• Suburban Continue

15. Roughly what percentage of your patients are…

	1-24%	25-49%	50-74%	75-100%	Don’t know
Hispanic or Latino?
Asian, Native Hawaiian, or Pacific Islander?
American Indian or Alaska Native?
Black or African American?

16. Roughly what percentage of your patients are insured by …

	1-24%	25-49%	50-74%	75-100%	Don’t know
Private insurance?
Medicare?
Medicaid?
Are uninsured?

[FOR SURVEYS: CONTINUE WITH INFORMED CONSENT]

Termination Language:

Thank you very much for your time today. You do not qualify for the survey. Thank you for your interest.

Screener for Health Care Providers for DSMES Brand and Concept Testing 6