2 Demographics

2 Demographics.docx

Survey of Eligible Users of the National Practitioner Databank

2 Demographics

OMB: 0915-0366

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OMB Number: 0915-0366; Expiration date: XX/XX/202X


Entities Survey: Module 2

Number of questions: 2


Demographic Information


We are collecting demographic information so that we can describe the different kinds of NPDB entities participating in this survey.


Q 2.1. In what region of the country is your organization located? If your organization operates in multiple regions, select all that apply by rank ordering them.


Region 1: Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, or Vermont

Region 2: New Jersey, New York, Puerto Rico, or Virgin Islands

Region 3: Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, or West Virginia

Region 4: Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, or Tennessee

Region 5: Illinois, Indiana, Michigan, Minnesota, Ohio, or Wisconsin

Region 6: Arkansas, Louisiana, New Mexico, Oklahoma, or Texas

Region 7: Iowa, Kansas, Missouri, or Nebraska

Region 8: Colorado, Montana, North Dakota, South Dakota, Utah, or Wyoming

Region 9: Arizona, California, Hawaii, Nevada, American Samoa, Northern Mariana Islands, Federated States of Micronesia, Guam, Marshall Islands, or Republic of Palau

Region 10: Alaska, Idaho, Oregon, or Washington


Q 2.2. Which of the following best characterizes your organization?


My organization reports adverse actions or malpractice payments to the NPDB that occur in my organization’s region (e.g., an independent hospital located in one area or a hospital system reporting from a single area).


My organization reports adverse actions or malpractice payments to the NPDB that occur in multiple regions (e.g., a hospital system located in multiple regions and reporting from the respective regions).


Survey Page Break


Q 2.3. Which of the following best describes your organization? Select one category.


Hospital or Hospital System

Health Plan

Other Health Care Entities (e.g., Group Practice, Community Health Center, Clinic, Urgent Care or Ambulatory Health Care Facility or another health care organization that is not a hospital)

Professional Society

Medical Malpractice Payer

State Licensing Board or State Certification Authority

Federal Licensing Agency

Federal or State Prosecutor (including Attorney General)

Other State Agency

Other Federal Agency

Authorized Agent for NPDB Registered Health Care Entities

Other (Please Explain)__________


Depending on the participant’s response above, survey will be directed to the next module as described below (see further details in the survey flowchart):


Hospital or Hospital System Module 3

Health Plan Module 4

Other Health Care Entities Module 4

Professional Society Module 5

State Licensing Board Module 6

State Certification Authority Module 6

Federal Licensing Agency Module 6

Federal or State Prosecutor (including Attorney General) Module 7

Other State Agency Module 8

Other Federal Agency Module 8

Other (Please Explain) Module 8

Authorized Agent for NPDB Registered Health Care Entities Module 24

Medical Malpractice Payer Module 31



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