Att 6_ Focus Group Recruitment Spreadsheet

Form Approved

OMB No. 0920-0840

Expiration Date: 10/31/2021

Virtual Focus Groups with Primary Care Physicians and OBGYNs:
Attitudes about Proposed Hepatitis C Screening Guidelines

DVH 2019

Attachment #6

Focus Group Recruitment Spreadsheet

Privacy Act Statement:

This information is collected under the authority of the Public Health Service Act, Section 301, "Research and Investigation," (42 U.S.C. 241); and Sections 304, 306 and 308(d) which discuss authority to maintain data and provide assurances of confidentiality for health research and related activities (42 U.S.C. 242 b, k, and m(d)). This information is also being collected in conjunction with the provisions of the Government Paperwork Elimination Act and the Paperwork Reduction Act (PRA). This information will only be used by the Centers for Disease Control and Prevention (CDC) staff to inform activities of the Division of Viral Hepatitis (DVH).

Public reporting burden of this collection of information is estimated to average 10 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: OMB-PRA (0920-0840)

Focus Group Recruitment Spreadsheet

Audience:

Group Date:

Group Time:

Q1

Q2

Q3

Q4

Q5

Q6

Q7

Q8

Q9

Q10

Q11

Q12

Recruit #

Gender

Medical specialty

Sub-specialty, if applicable

Year, med. school completion

Name, med. school completed

Year, residency completion

Primarily responsible, patient care?

Hours per week, direct patient care

Affiliations

Practice setting

Accepts Medicaid

Focus group or interview, last 6 mo.?

1

2

3

4

5

6

7

8

9

10

11

12