3 Individuals - Demographics

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

Self-Queriers Survey: Module 3

Number of questions: 10

Demographic Information

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

Q 3.1. Which category best describes your status in the health care industry? Select all that apply.

Full-time practice

Part-time practice

Locum tenens

Undergoing training to be a health care practitioner

Retired but practicing part-time

Retired and not practicing  Skip to Module 4

Currently not practicing (not retired)  Skip to Module 4

Survey Page Break

Q 3.2. Please select your current primary practicing position held as a health care practitioner.

Physician (Doctor of Medicine)

Physician (Doctor of Osteopathy)

Chiropractor

Dentist

Dental Hygienist

Advanced Practice Registered Nurse

Registered Nurse

Licensed Practical or Vocational Nurse

Nursing Para-Professional

Optometrist

Pharmacist

Physician Assistant

Podiatrist

Psychologist

Social Worker

Other Behavioral Health Provider (e.g., Pastoral Counselor, Mental Health Counselor, etc.)

Therapist (e.g., Physical Therapist, Massage Therapist, etc.)

Health Care Technician and Assistant (e.g., Radiologic Technician, Physical Therapy Assistant, etc.)

Other (Please Explain) ____________

Q 3.3. Do you currently practice at more than one facility?

Yes  If yes, go to Q 3.4, otherwise skip to Q 3.5.

No

Other (Please Explain) _________

Not Applicable

Q 3.4. If you currently practice at more than one facility, how many?

2

3

4

5 or more

Not Applicable

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Q 3.5. Please select the jurisdiction(s) in which you practice most of the time. You may select up to five.

Alabama

Alaska

American Samoa

Arizona

Arkansas

California

Colorado

Connecticut

Delaware

District of Columbia

Florida

Georgia

Guam

Hawaii

Idaho

Illinois

Indiana

Iowa

Kansas

Kentucky

Louisiana

Maine

Maryland

Massachusetts

Michigan

Minnesota

Mississippi

Missouri

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

North Carolina

North Dakota

Northern Mariana Islands

Ohio

Oklahoma

Oregon

Pennsylvania

Puerto Rico

Rhode Island

South Carolina

South Dakota

Tennessee

Texas

Utah

Vermont

Virgin Islands

Virginia

Washington

West Virginia

Wisconsin

Wyoming

Overseas Military

Canada

Other Foreign Country

Not Applicable

Survey Page Break

Q 3.6. Please select the jurisdiction(s) in which you are currently licensed or certified to practice. Select all that apply.

Alabama

Alaska

American Samoa

Arizona

Arkansas

California

Colorado

Connecticut

Delaware

District of Columbia

Florida

Georgia

Guam

Hawaii

Idaho

Illinois

Indiana

Iowa

Kansas

Kentucky

Louisiana

Maine

Maryland

Massachusetts

Michigan

Minnesota

Mississippi

Missouri

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

North Carolina

North Dakota

Northern Mariana Islands

Ohio

Oklahoma

Oregon

Pennsylvania

Puerto Rico

Rhode Island

South Carolina

South Dakota

Tennessee

Texas

Utah

Vermont

Virgin Islands

Virginia

Washington

West Virginia

Wisconsin

Wyoming

Canada

Other Foreign Country

Not Applicable

Q 3.7. For how long have you been working as a health care practitioner? (Select the numbers of months and years from the dropdown options.)

______ years

Dropdown menu options: 0 to 50.

______ months

Dropdown menu options: 0 to 12.

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Q 3.8. Do you intend to continue to work as a health care practitioner in the foreseeable future?

Yes  End this module.

No

Survey Page Break

Q 3.9. When do you intend to stop working as a health care practitioner?

Textbox

Q 3.10. What are your reasons for wanting to stop working as a health care practitioner?

Textbox

Piping logic:

Survey will be directed to Module 4 next.