Form 1 Attachment10 National_Awardee and Site Recruitment Mater

OMB# 0915-0368
Expiration Date XX/XX/XXXX

Attachment 10: Introductory and Recruitment Materials for Health Centers

10.1 RTI LEAD LETTER TO AWARDEES

10.2 RTI LEAD LETTER TO HEALTH CENTERS

10.3 HRSA LEAD LETTER TO AWARDEES AND HEALTH CENTERS

10.4 REFUSAL CONVERSION LETTER TO AWARDEES

10.5 AWARDEE AND SITE FREQUENTLY ASKED QUESTIONS

10.6 PATIENT FREQUENTLY ASKED QUESTIONS

10.7 AWARDEE RECRUITMENT GUIDELINES

10.8 HEALTH CENTER RECRUITMENT GUIDELINES

10.9 LETTER OF AGREEMENT FOR PARTICIPATING HEALTH CENTER

10.10 SCRIPTS FOR RESPONDENT RECRUITMENT BY RECEPTIONIST

RTI Lead Letters to Awardees and health centers

10.1 RTI LEAD LETTER TO AWARDEES

DATE

DIRECTOR

ADDRESS

CITY, STATE ZIP

Dear [DIRECTOR],

On behalf of RTI International and the Health Resources and Services Administration (HRSA), we would like to request your participation in the Health Center Patient Survey (Patient Survey). This survey aims to collect nationally representative data on patients who use health centers funded under Section 330 of the Public Health Service Act, to support HRSA’s mission to improve health and achieve health equity through access to quality services.

Your organization is one of a stratified sample of only 210 awardees selected to participate in this study. Therefore, your assistance is essential. We would like to involve some of your health center sites in this survey, which will be conducted sometime between June to December 2020. The survey data collection activities will be scheduled at your convenience. We will ask your health centers to allow RTI to conduct one-on-one private, personal interviews with a sample of patients who have received services in the previous year. On average, each interview will take 1 hour. Copies of the questionnaire are available for your review.

All information obtained during the Patient Survey will be kept private and without personal identifiers and will be used for research purposes only. We will work with you and the health center staff to ensure that the data collection activities adhere to the research requirements of your facilities. We also assure you and the health center staff that the findings from the Patient Survey will not be used to assess the performance of the individual health center or awardee.

In the next week, NAME OF AWARDEE RECRUITER, a member of the RTI research team, will contact you to discuss this request in more detail, to obtain health center-related information necessary for conducting the survey, and to answer any questions or concerns that you may have. If you prefer, you may contact him/her by calling toll free (800) XXX-XXXX, extension _____. We recognize that participation may present a variety of challenges, but our hope is that you will permit us to work with you and your health center staff to develop a plan that will effectively address any concerns and enable your participation.

Thank you in advance for your time and thoughtful consideration.

Sincerely,

Kathleen A. Considine
RTI Project Director

Enclosures: HRSA Letter of Support and RTI Brochure

10.2 RTI LEAD LETTER TO HEALTH CENTERS

DATE

DIRECTOR

ADDRESS

CITY, STATE ZIP

Dear [DIRECTOR],

On behalf of RTI International and the Health Resources and Services Administration (HRSA), we would like to request your participation in the Health Center Patient Survey (Patient Survey). This survey aims to collect nationally representative data on patients who use health centers funded under Section 330 of the Public Health Service Act, to support HRSA’s mission to improve the health of the nation’s medically underserved communities and populations and ensure their access to high-quality primary health care services.

Your health center was one of 210 randomly selected from across the country for participation in this study, and your site was selected within your awardee. Therefore, your assistance is essential. We have already spoken with your awardee and received permission to contact you about this important study. This study will be conducted sometime between June to December 2020 and will be scheduled at your convenience. Your participation involves allowing RTI to conduct one-on-one private, personal interviews with a sample of patients who have received services at your health center in the previous year. On average, each interview will take 1 hour. Copies of the questionnaire are available for your review.

All information obtained during the Patient Survey will be kept private and without personal identifiers and will be used for research purposes only. We will work with you and your staff to ensure that the data collection activities adhere to the research requirements of your facilities. We also assure you and the health center staff that the findings from the Patient Survey will not be used to assess the performance of the individual health center or awardee.

In the next week, NAME OF AWARDEE RECRUITER, a member of the RTI research team, will contact you to discuss this request in more detail, to obtain site-related information necessary for conducting the survey, and to answer any questions or concerns that you may have. If you prefer, you may contact him/her by calling toll free (800) XXX-XXXX, extension _____. We recognize that participation may present a variety of challenges, but our hope is that you will permit us to work with you and your staff to develop a plan that will effectively address any concerns and enable your participation.

Thank you in advance for your time and thoughtful consideration.

Sincerely,

Kathleen A. Considine
RTI Project Director

Enclosures: HRSA Letter of Support and RTI Brochure

HRSA Lead Letter to Awardees and Health centers

HRSA LETTERHEAD

10.3 HRSA LEAD LETTER TO AWARDEES AND HEALTH CENTERS

DATE

Dear Colleague:

The Health Resources and Services Administration (HRSA) is sponsoring the Health Center Patient Survey (Patient Survey) to be conducted by RTI International, a not-for-profit research firm. The Patient Survey will collect nationally representative data on patients who use health centers funded under Section 330 of the Public Health Service Act, to support HRSA’s mission to improve health outcomes and eliminate health disparities through access to quality services.

HRSA has selected your health center to assist us in this important work, and we would appreciate your support. Specifically, your staff will be asked to help identify patients willing to be interviewed for the Patient Survey and allow RTI staff to conduct personal interviews with the selected patients.

The study will involve the selection of a specific number of patients to participate in a personal interview with an RTI representative. We will treat all information obtained during the study as confidential, and it will be used for research purposes only. Furthermore, we will work with you and your staff to ensure that the data collection activities adhere to the research requirements of your facility.

For more detailed information on this study, please read the enclosed materials from RTI, and notify them if you are able to participate. We look forward to expanding upon the 2014 Health Center Patient Survey, and understanding how health center patients perceive their quality of care and the role health centers play in providing access to quality primary health care services.

Thank you in advance for your time and consideration. Sincerely,

Associate Administrator

Bureau of Primary Health Care

Health Resources and Services Administration

refusal conversion letter to Awardees

10.4 REFUSAL CONVERSION LETTER TO AWARDEES

DATE

DIRECTOR

ADDRESS

CITY, STATE ZIP

Dear [DIRECTOR],

I am respectfully asking for your organization to reconsider our request to conduct the Health Center Patient Survey at [NAME OF AWARDEE] sites. After all, this project shares the same goals as your organization, improving the health of underserved communities and vulnerable populations.

The Health Center Patient Survey is extremely valuable for the Health Resources and Services Administration (HRSA), to better understand the health care needs of the underserved populations. Your organization is one of about 210 awardees that were chosen to represent community health centers nationwide.

I am mindful of the numerous constraints on your time and that of your staff. I want to make clear that this project requires very little preparation on your part between now and when interviewing starts. Data collection is scheduled to begin in June 2020 and runs through December 2020. We can certainly conduct the interviews during a period of time that is amenable to your organization’s schedule. We are willing to work with you, only sending an interviewer at a time that is beneficial for you.

There will be very little burden to the site staff. The schedule for the data collection at each site will be determined by your needs set by the sites (or your organization). This includes the dates and times for data collection, as well as any other restrictions specifically set by the sites. We use only professional interviewers who are trained to be as unobtrusive as possible.

Therefore, I am hoping that this better understanding of the study will elicit your cooperation. I will be happy to speak to you, or any other officials of your organization to discuss the survey in more detail and answer any other questions you or they may have regarding participation. If needed, I can attend any kind of conference call with you and/or any of your officers.

Thank you in advance.

Kathleen A. Considine
RTI Project Director

AWARDEE AND SITE FREQUENTLY ASKED QUESTIONS

10.5 Awardee and Site Frequently Asked Questions

(NOT FOR DISTRIBUTION, FOR RECRUITER USE ONLY)

_{What is this study about?}

The Health Center Patient Survey is sponsored by the Health Resources and Services Administration (HRSA). The intent of this project is to collect nationally representative data on patients who use health centers that are funded under Section 330 of the Public Health Service Act. The results of this survey will guide and support HRSA in its mission to improve health and achieve health equity through access to quality services.

What do you mean by type of funding?

Type of funding means that the site receives a grant for operational support under the Health Center

Program, which includes:

• CHC – Community Health Center

• HCH – Health Care for the Homeless

• PHPC – Public Housing Primary Care

• MHC – Migrant Health Center

_{How was I selected for this study?}

We have selected 210 unique awardees to participate in the studies to achieve the target of 9,000 completed patient interviews. Awardees were eligible for selection if they participated in one or more of HRSA’s four funding groups (CHC, HCH, PHPC, and MHC). To ensure a nationally representative awardee sample, awardees were selected based on the types of funding they received and the number of patients they served. Awardees are also distributed among various regions, and urban and rural locations. To maintain a representative sample, it is important that we are able to work with every one of the selected awardees.

Once we have awardee approval, the individual eligible sites are selected based on the number of patients under each specific funding program and whether or not the sites are within a manageable distance for one field interviewer to cover.

What makes a site eligible?

• The site participates in at least one of the four specific types of funding (CHC, HCH, PHPC, or

MHC) and must have been operating under the awardee for at least 1 year.

• The site is not a school-based health center.

• The site is not a specialized clinic, excepting clinics providing OB/GYN services.+

• The site serves at least 100 patients.

Awardee and Site Frequently Asked Questions, con’t.

_{Why should my sites participate? How is this going to benefit us?}

This project shares the same goals as (you and your sites/you): improving the health of underserved communities and vulnerable populations. Interviewing a representative sample of patients from the awardees and sites that have been selected for this study will help us learn more about these patients’ medical needs and the ways in which they are using the health centers that receive funding to serve these populations.

Prior patient surveys were extremely valuable for comparing health center patients to patients nationally, and for demonstrating the quality of services provided by the health center programs. HRSA used the results extensively to meet performance reporting requirements. The information from the Patient Survey will enable HRSA to better serve and improve the health of the underserved populations. Participants will contribute to a valuable data set that documents the experience of health center patients.

At the conclusion of the study, each awardee will be provided with a report that summarizes our findings at the national level and also provides them with information about how their patients compare to the average patients in the survey. Only the awardee will receive its own report.

How many sites will you select for each Awardee?

(Recruiter: Choose the one most appropriate answer for the Awardee that you are talking to.)

IF THE AWARDEE HAS 3 OR FEWER ELIGIBLE SITES PROVIDE THIS ANSWER:

“All 3 will be selected.”

IF THE AWARDEE HAS MORE THAN 3 ELIGIBLE SITES, BUT ONLY RECEIVES ONE TYPE OF FUNDING (CHC, HCH, PHPC, OR MHC) PROVIDE THIS ANSWER:

“3 sites will be selected.”

IF THE AWARDEE HAS MORE THAN 3 ELIGIBLE SITES AND RECEIVES MORE THAN ONE TYPE OF FUNDING (CHC, HCH, PHPC, OR MHC) PROVIDE THIS ANSWER:

“At least 3 sites will be selected.”

Note that the number of patients that will be interviewed for each awardee will be based on the number of types of funding, not on the number of sites selected.

How many patients will you interview at each selected site?

(Recruiter: Choose the one most appropriate answer for the Awardee that you are talking to.)

QUICK RESPONSE FOR AWARDEES THAT ONLY SERVE CHC: “We will interview a total of

~XX patients.” IF THE AWARDEE HAS MORE THAN ONE SITE ALSO SAY THIS: “These XX interviews will be evenly divided amongst your eligible sites.”

Awardee and Site Frequently Asked Questions, con’t

RESPONSE FOR AWARDEES THAT SERVE SPECIAL POPULATIONS (HCH, PHPC, MHC): “The number of patients allocated to a particular awardee will be divided between the selected sites, but not necessarily evenly.” RECRUITER: CALCULATE THE ESTIMATED NUMBER THAT WILL BE ALLOCATED TO THE AWARDEE AND PROVIDE THEM WITH THAT NUMBER. THIS IS THE FORMULA: MULTIPLY XX TIMES THE NUMBER OF TYPES OF FUNDING (CHC, HCH, PHPC, OR MHC) THAT THE AWARDEE RECEIVES. ALSO PROVIDE THE FOLLOWING INFORMATION TO THE AWARDEE: Once you have given us the information that we need about each site, we will draw the site sample and our statistician will let us know which sites are selected and how many patient interviews will be allocated to each of the selected sites. You will be contacted with the information about the selected sites and the interviewing goal at each site before we contact the individual sites.

_{What do you need from the health care sites? What is the burden to the sites?}

There will be very little burden to the site staff. An RTI research interviewer will be present at your sites and will conduct the interview with the patients. The schedule for the data collection at each site will be set by the site. Our data collection period runs from June through December 2020 and we know that your sites are busy and will respect your choice of the best days to be present in your site. We won’t know how many days we will be present at the site until we are given the individual site quotas.

Our interviewer will need a space within your site in which to conduct the interviews in privacy. If there is a small room available with a desk or table and chairs; that would be ideal. But we will work with the site personnel to select the best space for the interviewer and the patient and, if necessary, we will change the space as the daily needs of the site dictate.

• We will need a point of contact person for the time that we are at each site. We are asking for about 90 minutes of time for that person to participate in a telephone discussion a few weeks before the scheduled data collection, so that we can explain our project and plan the daily flow of activity to minimize the burden on site staff.

• We will need a representative from each site to serve as a contact during our visit, should any situations arise that indicate that a respondent intends to harm themselves or others.

• We will need the assistance of a receptionist (or the person who logs in the patients each day) to introduce our study to the patients as they sign in for services. There is a very short script that we ask them to read to the patients. This script explains that the interview asks about their health

care experiences. The patients will be presented with a brochure explaining the study and it will then be up to them to decide if they wish to participate. Our interviewers will only interview patients who come to them at the site. The interview will last for approximately 60 minutes for adults, 50 minutes for adolescents, and 45 minutes for a child-proxy and there will be a cash or gift incentive for each participating patient.

All of our forms and questionnaires are available to the Awardee and Site Directors for review.

Awardee and Site Frequently Asked Questions, con’t

_{Will patients be asked about their citizenship or immigration status?}

_No. Patients will not be asked about their citizenship or immigrations status. The survey is not associated with any immigration laws and the agency sponsoring the study is not associated with an immigration agency. Any information the patient provides will not be used to determine their citizenship or immigration status. Their participation will not affect any services they receive at the health center.

_{How many interviewers will be involved and how long will they be at the sites?}

We will work with the sites to determine the least intrusive schedule. We have assigned one interviewer to each awardee to administer the survey at all of the awardee’s sites. However, we can certainly make arrangements to bring in a second interviewer in order to shorten the length of time we need to be on site. I can give you a more specific timeframe after we have the information that we need about each site to allow our statisticians to select the sites and assign patient quotas. Understand that the days at each site do not necessarily have to be consecutive. Again, our goal is to work with the sites to determine the least intrusive schedule for their site.

What are the questions that you will be asking our patients?

The questions in the Patient Survey ask about the patient’s general health conditions, access to health care, routine health care received in the past 12 months, follow-up care received in the past 12 months, frequency of visits, experiences with cancer screening, use and effects of smoking, alcohol and drugs, thoughts about suicide, dental and mental health problems encountered, HIV testing and health insurance, if any. Not all patients will answer all questions, as presence of health conditions will determine the flow of the interview.

_{What guarantees do our patients have of privacy and confidentiality?}

Patient privacy and protection are a primary concern of all RTI staff and we will meet any requirements to provide this for each site. RTI requires signed informed consent for our Patient Survey, which will require the interviewers to read to the respondent information about the survey and what is involved with individual participation.

We will not collect the names of our respondents, but will address them anonymously, or by using their first name or initials. We will not collect street addresses or telephone numbers unless we need this information to schedule an interview (at their request) off site. Any name or address information learned by the interviewers will not be data entered or otherwise attached to the data that is collected in CAPI.

Other protective measures for the Patient Survey include:

• informing respondents up front that some of the questions may be sensitive in nature and that they have the right to refuse to answer any questions;

• reassuring all subjects that they are under no obligation to respond to the interview and may terminate their participation at any time;

• informing participants that their answers are private, and that their names will not be associated with responses provided;

• conducting the interviews in a private location;

• reporting information obtained from the interviews only in summary form.

All RTI staff members assigned to the Patient Survey are required to sign and abide by a Staff

Privacy Pledge.

Information to be Included as Part of a
Trifold Brochure

10.6 INFORMATION TO BE INCLUDED AS PART OF A TRIFOLD BROCHURE

Frequently Asked Questions About the Health Center Patient Survey

Frequently Asked Questions About the Health Center Patient Survey, con’t

Awardee/Health center
Recruitment Guidelines

10.7 AWARDEE RECRUITMENT GUIDELINES

SUGGESTED INTRODUCTION SCRIPT:

[ASK FOR CONTACT PERSON IDENTIFIED IN VERIFICATION CALL]

Hello, my name is ________________ and I’m calling on behalf of HRSA about the Health Center Patient Survey. I’m calling from RTI International, which has been contracted to conduct the Patient Survey. I was given your name as the person in your office that is the most knowledgeable about the health center sites that your organization funds via Section 330 funding. I recently mailed study information to you. I am calling today to discuss the survey in more detail and answer any questions that you may have regarding participation. Do you have time to talk with me now? [THE FIRST CALL MAY LAST 10 MINUTES]. [IF NO]…I will be happy to call back at a time that is more convenient for you. [SET UP APPOINTMENT DATE AND TIME]

THE FOLLOWING MUST BE DISCUSSED DURING THE INITIAL OR SUBSEQUENT CALLS:

1. Give summary of the Patient Survey. Include purpose and major tasks.

The purpose of this survey is to obtain nationally representative data about the health and health care needs of patients who received services at Section 330 funded health centers. The national study will provide policy makers and service providers with a better understanding of the health problems and needs of these patients, their health care utilization, and met and unmet needs.

2. Clarify our request.

We are seeking permission from the awardees to collect data at a sample of their health centers. We are requesting information on their health centers so that our statistician can select the sample of health centers. Each selected health center will be asked to allow RTI to conduct one-on-one private, personal interviews with patients who have used the health center in the previous year (approx.. XX interviews per awardee, X or X per health center). Copies of the interview questions are available for awardee review.

3. Identify any perceived barriers to participation and work out plans to alleviate such barriers.

4. Discuss the approval process that is required at the Awardee level. Do they have an IRB and/or Board of Governance? If so, when is their next meeting? Offer assistance in obtaining study approval and/or gaining their cooperation. RTI must receive written notification of approval, if applicable. Discuss and document local requirements for obtaining informed consent from minors and proxies.

5. Address concerns about patient protection. Protective measures for the patient survey include:

• informing respondents up front that some of the questions may be sensitive in nature and that they have the right to refuse to answer any questions;

• reassuring all subjects that they are under no obligation to respond to the interview and may terminate their participation at any time;

• informing participants that their answers are private, and that their names will not be associated with responses provided;

• conducting the interviews in a private location;

• reporting information obtained from the interviews only in summary form;

Obtain the following information for each eligible health center associated with the Awardee. Eligible health centers are defined as follows:

• The health center should participate in at least one of the four specific funding programs and must have been operating under the awardee for at least 1 year.

• The health center is not a school-based health center.

• The health center is not a specialized clinic, except clinics providing OB/GYN services.

• The health center serves at least 100 patients.

Name of health center__________________________________

Contact Information

Name_________________________________

Title___________________________________

Address________________________________

Phone_________________________________

Email__________________________________

Fax___________________________________

Populations served (Circle Yes or No)

Migrant or seasonal farmworkers Yes / No

Homeless Yes / No

Public Housing Yes / No

Other (Community health) Yes / No

Number or Percent of users by population type during 2018:

Migrant or seasonal farmworkers

Homeless

Public Housing

Other (Community Health)

______Total

Type of health center (select one for Homeless Health center only)

Fixed serving homeless and general population

Fixed serving homeless only

Mobile serving homeless and general population

Mobile serving homeless only

Number or Percent of users during 2018 who were:

_______American Indian or Alaskan Natives

_______Native Hawaiian/Pacific Islanders

_______Asians

_______Veterans

_______65 years and over

Language

___% Clients speaking Spanish only

___% Clients speaking Mandarin only;

___% Clients speaking Cantonese only;

___% Clients speaking Tagalog only;

___% Clients speaking Vietnamese only;

___% Clients speaking other language; SPECIFY LANGUAGE ______________

6. After awardee agrees to participate, ask this contact for suggested sequence for other approvals/permissions. Specifically, are there approvals that must be acquired before contacting the health center or can we immediately make contact with the health center?

7. Discuss Letter of Agreement, if applicable.

10.8 HEALTH CENTER RECRUITMENT GUIDELINES

EXAMPLE SCRIPT FOR INTRODUCTION:

[ASK FOR PERSON THAT SHOULD HAVE RECEIVED THE ADVANCE PACKAGE]

Hello, my name is ________________ and I’m calling on behalf of HRSA about the Health Center Patient Survey. I’m calling from RTI International, which has been contracted to conduct the patient survey. I have already spoken with [GIVE NAME OF CONTACT AT THE AWARDEE ORGANIZATION] and he/she has given me permission to contact you about the survey. I sent you some materials in the mail about the survey. I am calling today to discuss the survey in more detail and answer any questions that you may have regarding participation.

Do you have time to talk with me now? [THE FIRST CALL MAY LAST 10 MINUTES]. [IF NO]…I will be happy to call back at a time that is more convenient for you. [SET UP APPOITMENT DATE AND TIME]

Have you had a chance to look over those materials? [IF NO]…. I will be happy to call back after you’ve had a chance to do so. [SET UP APPOINTMENT DATE AND TIME]

THE FOLLOWING MUST BE DISCUSSED DURING THIS CALL OR DURING SUBSEQUENT CALLS:

Give summary of the patient survey. Include purpose and major tasks.

The purpose of this survey is to obtain nationally representative data about the health and health care needs of patients who received services at Section 330 funded health centers. This national survey will provide policy makers and service providers with a better understanding of the health problems and needs of these patients, their health care utilization, and met and unmet needs.

Verify information obtained from awardee concerning contact information, users by race, users by age, % of users who only speak Spanish, Mandarin, Cantonese, Tagalog, and Vietnamese, and type of health center and eligibility criteria.

Clarify our request.

Each selected health center will be asked to allow RTI to conduct one-on-one private, personal interviews with people who have used the health center in the previous year (approx XX interviews per awardee, X or X per health center). Copies of the instruments are available for awardee review.

Discuss the schedule for data collection: June to December 2020. We will schedule the data collection at their convenience, but it must be conducted within this time frame. Let the health center know that an RTI interviewer will be conducting the interviews.

Ask about the health center’s days and hours of operation.

Assist in developing the health center-specific protocol for reporting situations of distress/abuse or harm to participants or others. Also, develop referral protocol for respondents requesting services or assistance. Obtain the name of an appropriate person at the health center or awardee organization for referrals, if applicable and appropriate.

Address concerns of patient protection. Protective measures for the patient survey include:

• informing respondents up front that some of the questions may be sensitive in nature and that they have the right to refuse to answer any questions;

• reassuring all participants that they are under no obligation to respond to the interview and may terminate their participation at any time;

• informing participants that their answers are private, and that their names will not be associated with responses provided;

• conducting the interviews in a private location;

• reporting information obtained from the interviews only in summary form.

Discuss study logistics.

Number of clients per day:

Migrant and seasonal farmworkers (if any)

Homeless (if any)

Public Housing (if any)

All other (Community Health)

Best time to interview clients

While awaiting receipt of services

After receiving services

Special appointment

Interviewing Space

Specify arrangement

Is space available for more than one interviewer at a time? Yes/No

Preference for respondent incentive (Mark all that apply)

Cash

Visa gift card

Food voucher

Discuss the Letter of Agreement, if applicable.

Letter of Agreement
for a Participating Health center

Public Burden Statement: The information collected through the Health Center Patient Survey (HCPS) informs HRSA on how health centers provide access to primary and preventative health care from the patients’ perspectives. It is the only nationally-representative survey of its type that focuses on the health care of populations seeking care at health centers. 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. The OMB control number for this information collection is 0915-0368 and it is valid until XX/XX/XXXX. This information collection is voluntary. Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or [email protected].

10.9 LETTER OF AGREEMENT FOR A PARTICIPATING HEALTH CENTER

<date>

<facility name>

<facility address 1>

<facility address 2>

Dear <administrator>

This letter will serve as an agreement between you and RTI International regarding your facility’s participation in the Health Center Patient Survey. As you know, the Patient Survey, sponsored by the Health Resources and Services Administration (HRSA) is being conducted by RTI, a not-for-profit organization based in North Carolina.

The purpose of this survey is to collect nationally representative data on patients who use health centers funded under Section 330 of the Public Health Service Act, to support HRSA’s mission to improve health and achieve health equity through access to quality services.

Please review the following information for accuracy:

1. Your health center’s administration has agreed to allow the facility to participate. The specific elements of participation were outlined in the Patient Survey overview that you received previously. The survey involves in-person interviews with patients aged 13 and older and in-person interviews with the parents/guardians of patients who are 12 years old and under. (For all interviews conducted with 13-17-year-olds, parental consent and minor assent will be obtained.) All data collected will be strictly private and will be used for research purposes only.

2. Your internal review process is complete, and the research is approved for implementation at your health center. No exceptions or stipulations were noted. <stipulate any exceptions here.>

3. The designated contact person from your health center is/are <include ALL contact names for Study survey>.

4. Your staff and RTI have determined the protocol for addressing subjects that may display significant emotional distress or volunteer other information that requires intervention or reporting. <state the protocol>

5. Data collection for the Patient Survey will be conducted between June to December 2020.

Your signature below indicates that you confirm/agree with the contents of this letter and that the Health Center Patient Survey can be initiated at your health center.

_____________________________ ___________________

<Name of Director> Date

Please make a copy of this letter for your records. Please email this signed letter to [RECRUITER email address]. After sending the letter, please return the original to RTI in the enclosed self-addressed stamped envelope.

If you have any questions now, or at any time during the study, please do not hesitate to call me at 1-800-334-8571, ext. 6612. We look forward to working with you and your staff. Again, thank you for participating in this study.

Sincerely,

Kathleen A. Considine

Project Director

cc:

script for Respondent Recruitment by receptionist

Health Center Patient Survey

10.10 Script for Respondent Recruitment by Receptionist

Respondent Recruitment Script – Adult Respondent

You have been invited to participate in an interview as part of an important research effort being conducted by RTI International and sponsored by the Health Resources and Services Administration (HRSA). The interview asks about your health care experiences and some other topics.

If you are eligible to complete the survey, you will receive $25 in cash or a gift of equal value as thanks for your participation. Here is a brochure that provides information about the study.

If you are interested in participating, or have any questions, please read the brochure and speak with the on-site RTI representative, _______________________. If the on-site RTI representative is not available and you would like to find out more information about the study, I can set an appointment for you to speak with her/him.

We hope you will choose to participate. Thank you!

Respondent Recruitment Script – Adolescent Respondent

Your child has been invited to participate in an interview as part of an important research effort being conducted by RTI International and sponsored by the Health Resources and Services Administration (HRSA). Your child will be asked questions about his/her health care experiences and some other topics. You will be asked a few questions about insurance coverage, marital status and veteran status.

If your child is eligible to complete the survey, he/she will receive $25 in cash or a gift of equal value as thanks for their participation. Here is a brochure that provides information about the study.

If you are interested in allowing your child participating and your child is willing, or you have questions, please read the brochure and speak with the on-site RTI representative, _________________________.

If the on-site RTI representative is not available and you would like to find out more information about the study, I can set an appointment for you to speak with her/him.

We hope you will choose to participate. Thank you!

Respondent Recruitment Script – Proxy Respondent

You have been invited to participate in an interview as part of an important research effort being conducted by RTI International and sponsored by the Health Resources and Services Administration (HRSA). The focus of the interview will be about your child. You will be asked to answer questions about him/her. The interview will ask about your health care experiences and some other topics related to your child.

If your child is eligible, you will complete the survey on their behalf and will receive $25 in cash or a gift of equal value as thanks for your participation. Here is a brochure that provides information about the study.

If you are interested in participating, or have any questions, please read the brochure and speak with the on-site RTI representative, _______________________________. If the on-site RTI representative is not available and you would like to find out more information about the study, I can set an appointment for you to speak with her/him.

We hope you will choose to participate. Thank you!

Public Burden Statement: The information collected through the Health Center Patient Survey (HCPS) informs HRSA on how health centers provide access to primary and preventative health care from the patients’ perspectives. It is the only nationally-representative survey of its type that focuses on the health care of populations seeking care at health centers. 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. The OMB control number for this information collection is 0915-0368 and it is valid until XX/XX/XXXX. This information collection is voluntary. Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or [email protected].