2 Appendix B: Individual Respondent Characteristics (Provi

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

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Building Diagnostic Safety Capacity – TeamSTEPPS® Course Evaluation

OMB: 0935-0179

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Appendix B – Individual Respondent Characteristics (Providers)



Shape1

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


Diagnostic Safety Capacity Building – TeamSTEPPS® Resource

Please complete the following information about yourself. This document is completed at the time of recruitment/interview/focus group

Individual Respondent Characteristics Survey (Provider)

Characteristic

Response Option*

Participant Category

  • Provider

  • Staff

  • Administrator

  • Other: _________________

Sex

  • Male

  • Female

Race

Check all that apply:

  • White

  • Black or African American

  • American Indian or Alaska Native

  • Asian

  • Other: ______________________

Ethnicity

  • Hispanic or Latino

  • Not Hispanic or Latino

Education Level

  • Elementary

  • High School Diploma

  • Some College

  • Associate degree

  • Bachelor’s degree

  • Master’s degree

  • Professional Degree

  • Doctorate

Age

Age (years): ___________

Location

City, State: ___________________________

Setting Type

  • Office-based practice

    • Primary Care

    • Specialty Care

    • FQHC

    • Multispecialty

  • Urgent Care Center

  • Skilled Nursing Facility

  • Hospital

  • Other: ____________________________

*Each characteristic must include an option for did not respond/did not provide an answer






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AuthorHill, Mary A
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