OMB Number: 0915-0366; Expiration date: XX/XX/202X
Entities Survey: Module 5
Number of questions: 9
This module is relevant for the following entity identified in Module 2:
Professional Society
Demographics Related Questions
Q 5.1. For the typical year, how many applications for membership does your professional society receive?
Type a number: __________
Do not know (Please Explain) ________
Q 5.2. For the typical year, how many membership applications does your professional society approve?
Type a number: __________
Do not know (Please Explain) ________
Q 5.3. For the typical year, how many members belong to your professional society?
Type a number: __________
Do not know (Please Explain) ________
Q 5.4. How many individuals in your professional society are responsible for granting membership to practitioners?
Type a number: __________
Do not know (Please Explain) ________
Q 5.5. How often does your organization review the records of practitioners that have been granted membership into your professional society?
Once every 6 months
Once per year
Once every 2 years
Once every 3 years
Once every 4 or more years
Ongoing
Records are never routinely reviewed after membership is granted.
Other (Please Explain)
Q 5.6. Which of the following sources does your professional society utilize for granting membership to a practitioner? (Please select all that apply.)
National Practitioner Data Bank (NPDB)
Practitioner’s Self-Queries of the NPDB
Board Action Data Bank of the Federation of State Medical Boards (FSMB) or other national organization(s) of state licensing boards for non-physician practitioners
Licensing board(s) in your state
Licensing board(s) in another state
Practitioner’s current medical malpractice/liability insurance carrier(s)
Practitioner’s previous medical malpractice/liability insurance carrier(s)
Practitioner’s current affiliated health plan(s)
Practitioner’s previous affiliated health plan(s)
Other health care entities (other hospitals, HMOs, group practice, etc.)
Professional society(ies) (e.g., AMA, AOA, ANA, etc.).
Medical school(s) or other professional school(s)
Residency program(s)
Speciality certification organizations (e.g., ABMS)
OIG exclusion list
Drug Enforcement Agency exclusion list
Peer or professional references
Other (Please Explain) ____________
Q 5.7. Has your professional society ever taken any NPDB reportable action(s)?
Yes
No Skip to Module 8
Q 5.8. In the last 5 years, how many times does your professional society take professional review actions regarding practitioners?
Dropdown menu: 0 to 10, more than 10
Do not know (Please Explain) _____________
If they say “zero”, then skip 5.9.
Q 5.9. In the last 5 years, how many times does your professional society take the following actions through a professional review process regarding practitioners? (Only one answer per row)
Dropdown menu for each item: 1 to 10, more than 10, Do not know
Revocation of Professional Society Membership
Suspension of Professional Society Membership
Disciplinary Probation Affecting Membership Rights or Privileges
Other Restriction/Limitation on Professional Society Membership (Specify) ____
Denial of Professional Society Membership (Subsequent)
Piping Logic:
Survey will be directed to Module 8 next.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Microsoft User |
| File Modified | 0000-00-00 |
| File Created | 2021-04-12 |