Form 16 Toolkit for Engaging Patients Provider Demographic Surve

Attachment R - Provider Characteristics Form

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

Toolkit for Engaging Patients
Provider Demographics Survey

Please take one minute to complete the following survey. It will help us to describe the providers who have implemented the Toolkit.

About You:

What type of provider are you?

• Physician

• Nurse Practitioner

• Medical Assistant

• Other (please identify)________________________________

How many years have you been a practicing provider?

• 0 to 5 years

• 6 to 10 years

• 11 to 15 years

• 16 or more years

Do you provide primary care or specialty care services?

• Primary care

• Specialty care (please identify) _____________________________________

Approximately how much of your professional time is spent providing care to patients? Please consider time spent on research, teaching, administrative duties, and other professional activities.

• 0-25% of time is spent providing care to patients

• 26-50% of time is spent providing care to patients

• 51-75% of time is spent providing care to patients

• 76-100% of time is spent providing care to patients

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 1 minute 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]