Ambulatory Unit Induction Interview

ATTACHMENT I:

AMBULATORY UNIT INDUCTION FORM

Department induction will be conducted in the ED

AMBULATORY UNIT INDUCTION FORM

OMB No. 0920-0278; Exp. Date: xx/xx/20xx

Assurance of confidentiality – We take your privacy very seriously.  All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes.  NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 U.S.C. 242m(d)) and the Confidential Information Protection and Statistical Efficiency Act of 2002 (CIPSEA, Title 5 of Public Law 107-347).  In accordance with CIPSEA, every NCHS employee, contractor, and agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you.  In addition, NCHS complies with the Federal Cybersecurity Enhancement Act of 2015 (6 U.S.C. §§ 151 & 151 note). This law requires the federal government to protect federal computer networks by using computer security programs to identify cybersecurity risks like hacking, internet attacks, and other security weaknesses. If information sent through government networks triggers a cyber threat indicator, the information may be intercepted and reviewed for cyber threats by computer network experts working for, or on behalf of, the government.

Notice – Public reporting burden for this collection of information is estimated to average 15 minutes per response, including 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 current valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing burden to: CDC/ATSDR Information Collection Review Office, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0278).

START

CENSUS CAPI SYSTEM

Ambulatory Unit Record

(Muliple ASL's were combined into this AU)

CASE STATUS IS: (New Case/ Call RO - Unable to locate/Interview Started/Folios not picked up/etc)

Reference Week: (Reference week) Press ALT-F9 to update AU/contact information

Press ALT-F11 to update AU schedule

1. Continue

2. Noninterview (Unable to locate, refusal, etc.)

3. Transmit for reassignment

4. Quit

SETUP_INFO

Enter the following information into the Web system.

AU Name: (facility name) Respondent's ID:(Case ID)

Select Form Used: (ED/OPD/ASC) Reporting Period: (Reporting Period) Start With: (start with number)

Take Every: (Take Every Number)

1. Enter 1 to Continue

SETUP_DONE

Have you finished setting up everything and filling out the form for the physician/staff?

1. Yes

2. No

ADMISSIONS_RES

This AU did not have any hospital admissions because the charts were unavailable at the time of abstraction.

Are the charts available now?

1. Yes, charts are available now

2. No, charts are still unavailable - continue to followup

3. Missing admissions info - final (No more followup)

LOG105_RES

There were PRFs with a disposition on "admitted to hospital" that had missing hospital discharge information.

Is that information available now?

1. Yes, information is available now

2. No, discharge information is still unavailable - continue to followup

3. Missing discharge info - final (No more followup)

UPDATE_PRF

Enter 1 and then press END to go to NEXT_PRF.

At NEXT_PRF, Enter 1 to update the appropriate PRF(s)

1. Enter 1 to Continue

NONINT_TYPE

Enter the type of noninterview 1.Unable to locate - Call RO 2.Abstraction delayed by facility

3.AU ineligible - not under auspices of hospital or FSASC 4.AU ineligible - only ancillary services provided

5.AU ineligible - care not provided by or under the direct supervision of a physician 6.AU ineligible - AU classified as out of scope

7.AU ineligible - other 8.Closed - Temporary 9.Closed - Permanent 10.Hospital Refused

11.Whole department Refused 12.Potential Refusal - followup required 13.Refused (TRANSMIT)

INTRO_INTERVIEW

DO NOT READ AS WORDED BELOW

• Identify yourself - show I.D.

• Ask to speak to:

(AU contact 1's name ) (2nd AU contact Name )

(Press ALT-F9 to update AU contact information) o Introduce survey, as necessary

• Press ALT-F11 to update AU schedule, if necessary 1.Continue

2.Reluctant Respondent 3.Inconvenient time 4.Other Outcome

PRIMARYCARE

Does this clinic provide predominantly primary care?

1.Yes 2.No

3.Unknown

AGREEEST

According to our information, there were (number of visits) patient visits during the reporting period. Is this correct?

Reporting Period: (Reference period)

1.Yes 2.No

ESTVISHR

How many visits did you have during the reporting period, (Reference period)

NUMTRLEV

How many levels are in this ESA's triage system? 1.Three

2.Four 3.Five

4. Other - Specify

5. Do not conduct nursing triage

NUMTRLEV_SP

Specify other triage levels

PRFHELP

Who will complete the PRFs? 1.FR

CINFO

Get a complete listing of all staff that will be assisting in the

data collection activities during the 4-week reporting period.

Press ALT-F10 to enter/update additional staff that will be assisting. Press ALT-F9 to enter/update main AU contacts

1. Enter 1 to Continue

SETUP_INFO

Enter the following information into the Web system.

AU Name: (facility name) Respondent's ID: (Case ID) Select Form Used: (ED/OPD/ASC)

Reporting Period: (Reporting Period) Start With: (start with number)

Take Every: (Take Every Number)

1. Setup Complete

2. Problem, setup later

PATIENT_LOG

Explain how to complete the Patient Log. Cover the following points

Include the following:

• List all patients receiving treatment during all hours of operation during the reporting period. Exclude the following:

  • Persons who visit only to leave a specimen, pick up a prescription or medication, or other visit where medical care is not provided;

  • Persons who visit to pay a bill, complete insurance forms, or for some other administrative reason;

  • Telephone calls or e-mail messages from patients;

  • Visits by persons currently admitted as inpatients to any other health care facility on the premises, that is, the sample hospital.

THANK

Thank you for your time and cooperation.

^LAPTOP_ACCOUNT

If you have any question (Hand contact your business card) please feel free to call me.

1. Enter 1 to Continue

2. Start Abstraction Now

1