Screening Form for Advanced Practice Providers and Physi

Form Approved

OMB Control No.: 0920-0572

Expiration date: 8/31/2021

FINAL - DHQP and NCEZID cleared.

Antibiotic Use Educational Effort – Recruitment Screener

Healthcare Provider (HCP)– Advanced Practice Providers and Physicians In Nursing Homes

Hello. My name is ________ and I work for [recruiting firm]. We are working with ICF, a consulting firm in Atlanta, Georgia, and the Centers for Disease Control and Prevention (CDC) to gather feedback from healthcare providers on CDC materials for a specific health topic. The interview will be online and last about one hour.

Do you think that you might be interested in participating in this type of interview?

• Yes

• No (Thank person for their time and end the conversation.)

May I ask you a few questions in order to determine whether you are a good fit to participate in the interview?

• Yes

• No (Thank person for their time and end the conversation.)

NOTE TO RECRUITER: Please terminate individuals as soon as they provide a response that makes them ineligible for participation. Please use the termination script below:

“We appreciate your willingness to answer each of the questions. Unfortunately, you do not meet all of the required criteria to participate in the interview. Thank you for your time.”

For those who are eligible for participation, move on to the next question.

Record and keep all screened data.

1. Are you a licensed physician, nurse practitioner, or physician assistant currently treating residents in a long-term care facility?

• Yes

• No (Thank person for their time, read termination script, and end the conversation.)

2. What type of provider are you? _______________

• MD or DO, Family Physician

• MD or DO, Gerontologist

• MD or DO, Internist

• Advanced Practice Registered Nurse (i.e. Nurse Practitioner)

• Physician Assistant

• Other (Thank person for their time, read termination script, and end the conversation.)

3. How many years have you been working in a nursing home? _____ years

[NOTE TO RECRUITER: Time working in NH does not have to be consecutive.]

• Less than 1 year (Thank person for their time, read termination script, and end the conversation.)

• 1 – 10 years

• More than 10 years

4. In what type of long-term care facility do you work?

• Nursing home (including skilled-nursing and/or long-term care)

• Assisted living (Thank person for their time, read termination script, and end the conversation.)

• Rehabilitation facility (Thank person for their time, read termination script, and end the conversation.)

• Long-term acute care facility (LTACH) (Thank person for their time, read termination script, and end the conversation.)

5. Would you describe your primary role as an administrator or as a clinical care provider? 

• Administrator (Thank person for their time, read termination script, and end the conversation.)

• Clinical care provider 

6. Do you serve as a primary clinician within the nursing home or do you mostly provide on-call coverage or moonlighting?

• Primary Clinician

• On-call coverage or moonlighting (Thank person for their time, read termination script, and end the conversation.)

7. In what type of nursing home do you work? __________ (Select all that apply) (Recruit a mix of independent vs. multi-facility, and for-profit vs. not-for profit)

• Multi-facility organization

• Independent organization

• For profit organization

• Not-for-profit organization

• Other

8. What state do you work in? _______________ (Recruit a mix of locations, including from a mix of urban and rural areas within the state)

• Alabama

• Arkansas

• Georgia

• Iowa

• Kentucky

• Louisiana

• Mississippi

• Missouri

• Nebraska

• Tennessee

• Texas

• West Virginia

• Other (Thank person for their time, read termination script, and end the conversation.)

9. Do you have access to a phone, computer, and reliable internet to participate in the discussion?

• Yes

• No (Thank person for their time, read termination script, and end the conversation.)

10. Thank you for answering those questions. You are eligible to participate in the interview. We will provide a $XX token of appreciation for participating in this discussion. Are you still interested in participating?

• Yes

• No (Thank person for their time, read termination script, and end the conversation.)

I’m glad that you are willing to participate! I have just a couple more questions and then will need to find the best time to schedule the discussion.

NOTE TO RECRUITER: Questions 11-13 do not affect eligibility. but aim to recruit a mix of participants by response category when noted.

11. What is your sex?

• Male

• Female

• Did not provide a response (Do not read as a response option)

12. Would you describe yourself as Hispanic or Latino?

• Yes

• No

• Did not provide a response (Do not read as a response option)

13. How would you describe your racial background? Select all that apply.

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or other Pacific Islander

• White

• Did not provide a response (Do not read as a response option)

14. Are you available at any of the following dates and times?

Actual dates and timeslots TBD – dependent on CDC/ICF/moderator availability.

Thank you. We will send you an invitation with a link to join the interview online and a telephone number to call in. Please join online AND dial in at your scheduled time. Now, please confirm the following contact information:

Name
Mailing Address
Home Telephone
Cell Phone
Email

We will send reminders about this interview to you. We will send you a confirmation notification via email, mail, and/or mobile device. Two days before the interview, we will send you a reminder email along with an informed consent form. Please read this form and return a signed copy before the scheduled interview. The day before the interview, we will call to remind you about this interview and send a reminder via text message. After the interview is over, we will send your token of appreciation after the interview is over to the mailing address that you provided.

Thank you for your time. Please contact [Recruiter] at [Phone Number] if you have questions or if your plans change and you are no longer able to participate in the discussion. Otherwise, we’ll look forward to talking with you on [Month/Day/Year] at [Time].

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 Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-0572