2 Site Information Form

Attachment B - Site Information Form

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Site Information Form

Please complete this form to provide more information about your (organization); it should take no longer that 20 minutes.

1. Site name:

Site Size

2. FTE:

3. Beds (if applicable):

Patient Mix

4. Patients served per year [N]:

5. % patients, by sex/gender

   1. Male:

   2. Female:

   3. Other:

6. % patients, by race

   1. American Indian or Alaska Native:

   2. Asian:

   3. Black or African American:

   4. Native Hawaiian or other Pacific Islander:

   5. White:

   6. More than one race:

   7. Other:

7. % patients, by ethnicity

   1. Hispanic/Latino:

   2. Not Hispanic/Latino:

This survey is authorized under 42 U.S.C. 299a. This information collection is voluntary and 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 20 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. The data you provide will help AHRQ’s mission to produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable. 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, or by email to the AHRQ MEPS Project Director at [email protected].

8. % patients, by primary language

   1. English:

   2. Spanish:

   3. Chinese:

   4. Tagalog:

   5. Vietnamese:

   6. Other:

9. % patients, by age category

   1. <18:

   2. 18-39:

   3. 40-64:

   4. 65-80:

   5. 80+:

10. % patients, by insurance

    1. Medicare:

    2. Medicaid:

    3. Private:

    4. Military:

    5. Other:

Commitments and Capacities

	Yes	No
Do you have site leadership (eg: C-suite, quality or patient safety team, department leadership) support of your participation in this evaluation?	¨	¨
Have you reviewed the master DUA?	¨	¨
12b. Are you able to pursue and obtain a data use agreement at your site as part of this evaluation?	¨	¨
Have you reviewed the IRB information packet?	¨	¨
13b. Are you able to pursue and obtain IRB approval as part of this evaluation?	¨	¨
Are you able to identify at least two participants who will be engaged in the implementation and evaluation?	¨	¨
Are you able to identify one site leader who will facilitate access to site-level resources for this evaluation, socialize the effort across the site, and engage with site participants as needed (can be respondent)?	¨	¨
Are you able to identify at least one site champion who will work closely with the project team to ensure successful implementation and evaluation, serve as a conduit between the project team and site participants, facilitate data access and transfer, and socialize the effort across participants?	¨	¨
16b. Can the site champion(s) participate in up to monthly learning collaborative training, implementation, and sustainment virtual meetings?	¨	¨
Have you reviewed the training, implementation, and sustainability activities and virtual meeting schedule?	¨	¨
17b. Are you able to commit the site/site participants to engage in all training, implementation, and sustainability activities and virtual meetings?	¨	¨
Have you reviewed all data collection activities and timing?	¨	¨
18b. Are you able to commit the site to engage in all data collection activities and timing?	¨	¨

19. Confirm which tool(s) will be implemented (check all that apply)

• Measure Dx

• Calibrate Dx

• Toolkit for Engaging Patients

Additional Information/Notes

Contact Information (add as needed per tool and per individual)

Tool name:

20. Site Leader 1

1. Name:

2. Email:

3. Phone number:

4. Alternate Contact name:

5. Alternate Contact email:

6. Alternate Contact phone number:

21. Site Champion 1

1. Name:

2. Email:

3. Phone number:

4. Alternate Contact name:

5. Alternate Contact email:

6. Alternate Contact phone number:

22. Participant 1

1. Name:

2. Email:

3. Phone number:

4. Alternate Contact name:

5. Alternate Contact email:

6. Alternate Contact phone number:

23. Participant 2

1. Name:

2. Email:

3. Phone number:

4. Alternate Contact name:

5. Alternate Contact email:

6. Alternate Contact phone number: