Respondent Info Form

Attachment 5a: Interview and Focus Group Respondent Information Form

Respondent Information for Interview and Focus Group Participants

1. Please provide the names and contact information for two to three individuals to receive the Key Informant Interview. These individuals may be the Oncology Service Line Administrator, Director of Quality Improvement, Psychosocial Service Coordinator, or someone who is knowledgeable about distress screening policies and practices at your healthcare facility.

Name	Title	Email	Phone number

2. Please provide the names and contact information for two or three individuals under each position/title to participate in a Focus Group. We are looking for individuals who interface with distress screening processes on a day-to-day basis.

Position/Title	Name	Email	Phone number
Oncology Social Worker
Physician
Mid-level Nurse Practitioner/Physician’s assistant
Clinical Nurse
Mental Health Professional
Palliative Care Consult
Spiritual Care Consult
Dietician
Pharmacist
Other