OMB Number: 0915-0366; Expiration date: XX/XX/202X
Entities Survey: Module 15
Number of questions: 15
This module is relevant for only those participants who received a matched response, as indicated in Module 14.
Matched Responses in Query
Q 15.1. What type of information did your organization ever receive as a result of conducting an NPDB query (regardless of one-time or continuous query)? (Please select all that apply.)
State Licensure Action Report
Reinstatement / Restoration Report
DEA/Federal Licensure Action Report
Title IV Clinical Privileges Action Report
Health Plan Action Report
Exclusion/Debarment Action Report
Professional Society Action Report
Peer Review Organization Action Report
Accreditation Action Report
Government Administrative Action Report
Criminal Conviction Report
Deferred Conviction or Pre-Trial Diversion Report
Nolo Contendere (No Contest) Plea Report
Civil Judgment Report
Injunction Report
Medical Malpractice Payment Report
Other (Please Explain) ________
Survey Page Break
Q 15.2. How often do your query results from the NPDB provide you with new information about practitioners that you did not obtain through other sources, including the practitioner’s application?
All the Time
Most of the Time
More than Half the Time
About Half the Time
Less than Half the Time
Rarely
Never
Not Applicable
Other (Please Explain) _________
If participants respond, “never” or “not applicable” or “other” above, skip the next question.
Q 15.3. What kinds of reports has your organization received which contained new information that it had not obtained through other sources (e.g., employment application of practitioners, query response from the FSMB, response to requests for information from previous work sites, etc.)? (Please select all that apply.)
State Licensure Action Report
Reinstatement / Restoration Report
DEA/Federal Licensure Action Report
Title IV Clinical Privileges Action Report
Health Plan Action Report
Exclusion/Debarment Action Report
Professional Society Action Report
Peer Review Organization Action Report
Accreditation Action Report
Government Administrative Action Report
Criminal Conviction Report
Deferred Conviction or Pre-Trial Diversion Report
Nolo Contendere (No Contest) Plea Report
Civil Judgment Report
Injunction Report
Medical Malpractice Payment Report
Other (Please Explain) _________
Q 15.4. What types of actions does your organization take when a query response contains adverse action reports, judgment or conviction reports, or medical malpractice payment reports on practitioners at your facility? (Please select all that apply.)
Initiate an Informal Investigation
Seek Additional Information
Conduct a Formal Peer Review
File Information for Scheduled Review
No Action Is Taken
Unknown
Not Applicable
Other (Please Explain) ________
Survey Page Break
Q 15.5. Which of the following decisions are affected by the information provided by the
NPDB? (Please select all that apply.)
Hiring of Staff
Firing of Staff
Credentialing
Monitoring
Proctoring
Granting Clinical Privileges
Licensing
Certification
Membership
Disciplinary Actions
Non-Disciplinary Actions
Not Applicable
Other (Please Explain) _______
Q 15.6. Would your decisions (selected in the previous question) regarding practitioner(s) have been different if you had not received the NPDB response?
Yes
No
Other (Please Explain) _________
If the response is “yes”, continue to next question, otherwise skip the next question.
Q 15.7. What percent of your decisions regarding practitioners would have been different if you had not received the NPDB response?
Select a number: ___ [drop down menu of 0 to 100]
Survey Page Break
Q 15.8. For each type of report listed below, please rate its effect on your organization’s decision to offer employment, credentialing, licensing, certification, or granting of clinical privileges if the practitioner had such a report in the NPDB. (Only one answer per row.)
Rating Scale
Neutral / Slightly Negative / Somewhat Negative / Moderately Negative / Extremely Negative
State Licensure Action Report
Reinstatement / Restoration Report
DEA/Federal Licensure Action Report
Title IV Clinical Privileges Action Report
Health Plan Action Report
Exclusion/Debarment Action Report
Professional Society Action Report
Peer Review Organization Action Report
Accreditation Action Report
Government Administrative Action Report
Criminal Conviction Report
Deferred Conviction or Pre-Trial Diversion Report
Nolo Contendere (No Contest) Plea Report
Civil Judgment Report
Injunction Report
Medical Malpractice Payment Report
Other (Please Explain) __________
Survey Page Break
Q 15.9. How often does your organization contact the original reporters for additional information when it receives reports resulting from querying the NPDB?
All the Time
Most of the Time
More than Half the Time
About Half the Time
Less than Half the Time
Rarely
Never
Not Applicable
Other (Please Explain)
Survey Page Break
Q 15.10. How often does information from the NPDB lead to further investigation into additional sources of information?
All the Time
Most of the Time
More than Half the Time
About Half the Time
Less than Half the Time
Rarely
Never
Not Applicable
Other (Please Explain) ___________
Q 15.11. Information received from the NPDB makes my organization confident about the decisions it makes concerning practitioners.
Rating Scale
Completely Agree / Agree / Neither Agree or Disagree / Disagree / Completely Disagree
Survey Page Break
Q 15.12. About how many times in the last 3 years did you receive a response regarding a practitioner other than the one on whom you attempted to query in the NPDB (e.g., a “mismatch”)? Select a number below. If you have never received such responses to your queries, select zero.
Select a number: ___ [drop down menu of 0 to 10]
If the response is 0 (zero), skip the next question.
Q 15.13. The last time this happened, what action did you take? (Select all that apply.)
None
Inform the NPDB
Obtained additional identification information and re-queried
Other (please explain) ____________
Survey Page Break
Q 15.14. About how many times in the last 3 years did you receive a non-response to a query from the NPDB (e.g., you were expecting a report but there was no disclosure of any report)? Select a number below. If you have never received such responses to your queries, select zero.
Select a number: ___ [drop down menu of 0 to 10]
If the response is 0 (zero), skip the next question and end this module.
Q 15.15. What does your organization do in the event of a non-response to a query (e.g., you were expecting a report but there was no disclosure of any report)? (Select all that apply.)
Nothing
Inform the NPDB
Obtained additional identification information and re-query
Other (please explain) ____________
Piping Logic:
Survey will be directed to Module 16 next.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Microsoft User |
| File Modified | 0000-00-00 |
| File Created | 2021-04-12 |