Form 0920-18AFX Focus Group Questionnaire

Attachment 7. Focus Group Questionnaire

Focus Group Questionnaire

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

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-XXXX).

1. What is your profession? (PLEASE SELECT ONE)

□ Physician

□ Nurse Practitioner

□ Physician Assistant

□ Other (specify):

2. How many total years have you practiced in that profession?  ________ years

3. What is your primary specialty? (PLEASE SELECT ONE)

□ Family Medicine

□ General Practice

□ Internal Medicine

□ Pediatrics

□ OB/GYN

□ Geriatrics

□ Emergency Medicine

□ Other primary specialty (specify):

□ Not applicable, no licensed or certified specialty 

4. What proportion of your patient population is pediatric? ________%

5. How would you describe the health care setting you practice in? (SELECT ALL THAT APPLY)

□ Emergency Department

□ Primary Care Practice

□ Other (specify):

5a. If you selected Primary Care Practice above, in what setting do you practice?

• Private practice (solo)

• Group practice

• Hospital-based practice

• Health clinic (e.g., RHC, FQHC, CHC)

6. What is your age? ____________

7. What is your sex?

□ Male

□ Female

8. What is your ethnicity?

□ Hispanic or Latino

□ Not Hispanic or Latino

9. What is you race? (SELECT ONE OR MORE)

□ American Indian or Alaska Native

□ Asian

□ Black or African American

□ Native Hawaiian or Other Pacific Islander

□ White

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