1a Appendix A_Respondent Characteristics_final_6 17 21

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

Appendix A_Respondent Characteristics_final_6 17 21

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 and will take approximately 15 minutes to complete. Participation in the survey is voluntary.


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

  • Native Hawaiian or Other Pacific Islander

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




Shape2

This survey is authorized under 42 U.S.C. 299a. The confidentiality of your responses to this survey is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)].  Information that could identify you will not be disclosed unless you have consented to that disclosure. Public reporting burden for this collection of information is estimated to average 15 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 5600 Fishers Lane, Room #07W42, Rockville, MD 20857.






2


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

© 2024 OMB.report | Privacy Policy