1 Appendix A: Individual Respondent Characteristics Survey

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

Appendix A_Respondent Characteristics_final

OMB: 0935-0179

Document [docx]
Download: docx | pdf

Appendix A – Individual Respondent Characteristics



Shape1

Form Approved
OMB No.
xxxx-xxxx
Exp. Date xx/xx/
20


Diagnostic Safety Capacity Building – Calibration Resource

Please complete the following information about yourself. This document is completed at the time of recruitment/interview.

Individual Respondent Characteristics Survey

Characteristic

Response Option*

Sex

  • Male

  • Female

Race

Check all that apply:

  • White

  • Black or African American

  • American Indian or Alaska Native

  • Asian

  • Other: ______________________

Ethnicity

  • Hispanic or Latino

  • Not Hispanic or Latino

Age in years


Professional Background

  • Physician (MD/DO)

  • Physician Assistant

  • Nurse Practitioner

Specialty and/or board certification(s)


Number of years in practice (since licensure)


Location

City, State: ___________________________

Practice Setting(s)

  • Office-based practice

    • Primary Care

    • Specialty Care

    • FQHC

    • Multispecialty

  • Urgent Care Center

  • Emergency Room

  • Hospital

  • Other: ____________________________

Organization type

Academic medical center

Other not-for-profit

 For-profit

Do you hold an academic appointment or affiliation?

  • Yes

  • No

Are you involved in training learners in your discipline (e.g., medical students, interns, residents, and/or fellows)?

  • Yes

  • No

*Each characteristic must include an option for did not respond/did not provide an answer





2


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorHill, Mary A
File Modified0000-00-00
File Created2023-11-13

© 2024 OMB.report | Privacy Policy