1 Appendix A: Setting Demographics Survey

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

Appendix A_final cg 11 12 20

Building Diagnostic Safety Capacity – TeamSTEPPS® Course Evaluation

OMB: 0935-0179

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Appendix A – Setting-Level Demographics Survey



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Form Approved
OMB No.
xxxx-xxxx
Exp. Date xx/xx/
20


Diagnostic Safety Capacity Building – TeamSTEPPS® Resource

Please complete the following information about your practice:

General Information About Your Practice

Practice Name


Mailing Address (City, State, Zip code)


Contact Person


Medical Director


Number of

Physicians

__________


Nurse Practitioners

___________


Nurses

__________


Medical Assistants

__________


Pharmacists

___________


Social Workers

__________


Case Managers

Other Practice Staff

__________

__________


Other (specify)

__________




Total Number of Patients Served by Practice


________

Payer Mix (Indicate % of Patients)

Self-Pay

Medicare

Medicaid

Private Insurance

Uninsured

Other

_________%

_________%

_________%

_________%

_________%

_________%



Race (indicate % of patients)


White

Black or African American

American Indian or Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

Multiple racial categories

_________%

_________%

_________%

_________%

_________%


_________%



Ethnicity (indicate % of patients)

Hispanic or Latino

Not Hispanic or Latino

_________%

_________%






Information about Previous Implementation of TeamSTEPPS® Strategies in the Setting


Yes

No

Has your organization implemented/ attempted to implement a TeamSTEPPS® training course in the past?



Please specify which TeamSTEPPS® Course you previously implemented: _________________

_________________




Information about Patient Safety and Quality Improvement Activities of the Setting


Yes

No

Does your practice routinely conduct a patient safety culture survey?




Please specify which survey you use: ________________

Date of the last survey: _________________


Is your practice part of a larger healthcare system?



Please indicate which health system you are affiliated with:

___________________


Is your practice currently working on any other practice improvement strategies?

Does your practice have or use the services of a practice facilitator?


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This survey is authorized under 42 U.S.C. 299a. The confidentiality of your responses to this survey is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)].  Information that could identify you will not be disclosed unless you have consented to that disclosure. Public reporting burden for this collection of information is estimated to average 60 minutes per response, the estimated time required to complete the survey. 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: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 5600 Fishers Lane, Room #07W42, Rockville, MD 20857.





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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorHill, Mary A
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File Created2021-01-13

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