0920-0572 Screener Health Care Providers

OMB No. 0920-0572

Expiration Date 3/31/2021

MESSAGE TESTING CARD SORT SCREENER FOR HEALTH CARE PROFESSIONALS

October 7, 2019

To be included on the first page: 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). 

Health care Providers Screener

1. Are you:

• Male CONTINUE

• Female CONTINUE

2. Are you a…

• Physician/MD/DO CONTINUE

• Nurse Practitioner or Advanced Practice Nurse CONTINUE

• Physician Assistant (PA) CONTINUE

• None of the above TERMINATE

3. [for Physician/MD/DO only] What is your medical specialty?

• Endocrinologist CONTINUE

• General Practice/General Medicine/

Internal Medicine/Family Medicine Physician CONTINUE

• Other TERMINATE

4. [for NPs and PAs only] Do you work in …?

• Endocrinology practice CONTINUE

• General Practice/General Medicine/

Internal Medicine/Family Medicine Physician Practice CONTINUE

• Other TERMINATE

5. Have you been diagnosed with diabetes by a health care provider?

• Yes TERMINATE

• No CONTINUE

• Do not know/Unsure TERMINATE

6. What percent of the patients you see are 18 years old and older?

• 100% CONTINUE

• 50-99% CONTINUE

• Under 50% TERMINATE

7. 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) CONTINUE

  • Health maintenance organization (HMO) CONTINUE

  • Medical school or parent university CONTINUE

  • Non-government hospital or clinic CONTINUE

  • City/county/state government hospital or clinic CONTINUE

  • US (federal) government hospital or clinic (e.g., Military or VA hospital) CONTINUE

  • Nonprofit community health center

(e.g., Federally Qualified Health Center) CONTINUE

• Other: Terminate

8. Roughly what percentage of the patients you see have type 1 or type 2 diabetes

• Less than 25% TERMINATE

• 25% or more CONTINUE

9. For how many years have you been treating patients at the time of their initial diabetes diagnosis or when they experience a diabetes-related health issue?

• Under 1 year CONTINUE

• 1-5 years CONTINUE

• 6-10 years CONTINUE

• More than 10 years CONTINUE

10. I’d like to know more about the different types of education to which you refer patients with diabetes, at any stage of their disease. What percentage of your patients with diabetes do you refer to services called diabetes self-management education and support. [INSERT PLAIN LANGUAGE DESCRIPTION HERE]. Would you say you refer at least 30 % of your patients with diabetes to these services?

• Less than 30% CONTINUE

• 30% or more CONTINUE

11. Roughly what percentage of your patients are…

	0%	1-9%	10-24%	25-49%	50-74%	75-100%	Don’t know
Hispanic or Latino?
American Indian or Alaska Native?
Black or African American?

12. Roughly what percentage of your patients…

	0%	1-9%	10-24%	25-49%	50-74%	75-100%	Don’t know
Are insured by Medicare?
Are insured by Medicaid?
Are uninsured?