CMS-10823 Appendix I

Appendix I: Participant Screeners
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection
of information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0938-XXXX (Expires XX/XX/XXXX). This is a voluntary information collection.
The time required to complete this information collection is estimated to average 30 to 60 minutes
per response, including the time to review instructions, search existing data resources, gather the
data needed, and complete and review the information collection. If you have comments concerning
the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS,
7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore,
Maryland 21244-1850. Please do not send applications, claims, payments, medical records or any
documents containing sensitive information to the PRA Reports Clearance Office. Please note that
any correspondence not pertaining to the information collection burden approved under the
associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If
you have questions or concerns regarding where to submit your documents, please contact
Christopher King at [email protected] or (410) 786-6972.
[The purpose of these screening documents is to collect attributes about the participant that the study
team is not able to obtain prior to recruitment that will impact the final recruitment targets. The answers
to some of these screening questions will also determine which questions are asked during the
interviews. Because the study only targeting specific attributes of facility administrators and patients,
there are no screening questions for the other participant types.]

I.1. Facility Administrator Screener
[This screener is intended for administration after the participant has agreed to participate in an
interview]
I have a few questions that I need to ask you that will help us understand the participants we recruit for
these interviews. You don’t have to answer any questions you don’t want to, but some of them are
necessary to determine which questions are asked during the interview.
May I continue?
[If yes, continue to Q1]
[If no] Thank you for your time, if you decide you are interested in providing this information you can
contact the study team at (571) 758-5036 or [email protected].
1. How many years have you been working with ESRD patients?
[Record response]:
I have a list of job titles, please tell me which ones apply to your current position at the dialysis
facility.
a. Facility Administrator
b. Registered Nurse (RN)
c. Nurse Manager
d. Medical Director

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e. Social Worker
f.

Other, please specify:

2. What is the size of your facility?
a. Number of patients
b. Number of stations
3. Does your facility offer home dialysis services?
a. Yes
b. No
4. Are you familiar with the Quality Incentive Program, otherwise known as the QIP? It is the
program that measures facility quality by tracking certain patient outcomes such as infections,
dialysis adequacy (or Kt/V), ICH-CAHPS scores, etc.
a. Yes
b. No
5. Would you describe your facility location as urban, rural, or suburban?
[Record response]:
6. [Only ask if we don’t already have the email address]: What is the best email address you would
like us to use when contacting you about the interview? We will not share It with anyone
outside the research team, and it will only be used to contact you about this study.
[Record email]:
7. [Only ask if we don’t already have their phone number]: What is the best phone number to
reach you?
[Record phone number]:
8. During the interview, we hope to record the conversation for notetaking purposes to make sure
we capture your remarks accurately. The recording does not get shared with anyone outside the
research team and is destroyed at the end of the study. Do we have your permission to record
the interview?
[Record response]: [If no, mark “notetaker needed” on recruitment tracker]
Thank you for this information. If you have time now, I would like to schedule the interview for when is
most convenient for you.
[PROCEED TO SCHEDULING INTERVIEW IF POSSIBLE]

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I.2. Patient Screener
[This screener is intended for administration after the participant has agreed to participate in an
interview]
Thank you for your interest in participating in our study! I have a few questions that I need to ask you
that will help us understand you better. You don’t have to answer any questions you don’t want to, but
some of them are necessary to determine which questions are asked during the interview.
May I continue?
[If yes, continue to Q1]
[If no] Thank you for your time, if you decide you are interested in providing this information you can
contact the study team at (571) 758-5036 or [email protected].
1. What is your age?
[Record response]:
2. What gender do you identify as?
[Record response]:
3. Do you identify as Hispanic, Latino, or of Spanish origin?
a. Yes
b. No
c. Prefer not to answer
4. Which race or races do you identify as?
[Record response]:
5. How many months/years have you been on dialysis?
[Record response]:
6. What is your zip code?
[Record response]:
7. What state do you live in?
[Record response]:
8. What modality do you currently receive dialysis in?
8a. [If home hemodialysis] Peritoneal Dialysis or Home Hemodialysis?
[Record response]:
8b. [If in-center] What facility do you receive your dialysis through?
[Record response]:

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9. Have you ever received a transplant?
a. Yes
b. No
c. Prefer not to answer
10. Would you say you live in an urban, rural, or suburban area?
[Record response]:
11. Finally, during the interview, we hope to record the conversation for notetaking purposes to
make sure we capture your comments accurately. The recording does not get shared with
anyone outside the research team and is destroyed at the end of the study. Do we have your
permission to record the interview?
[Record response]:
[PROCEED TO SCHEDULING INTERVIEW IF POSSIBLE]

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