Screener and Recruitment Question Bank
Attachment 3 - Screening and Recruitment Question Bank.docx
[NCEZID] Rapid Message Testing & Message Development System
Screener and Recruitment Question Bank
OMB: 0920-1432
Screening and Recruitment Question Bank
CDC NCEZID
I. OVERVIEW
The following is a collection of potential questions (question bank) to be used in recruiting and screening participants for research on behalf of NCEZID. These recruitment questions can be used to screen participants for surveys, focus groups, or in-depth interviews (in addition to many other methodologies). The questions are also used to set quotas on numbers or mixes of participants with different profiles within a sample (to ensure no more than X, no less than X, etc.).
This document should not be viewed as a single screening questionnaire. Rather, it is meant to serve as a bank of questions from which to select only those that are necessary to identify the desired respondents for a given research initiative.
II. PROFILE QUESTIONS, SCREENING, AND QUOTA QUESTIONS
MARKET RESEARCH EXPERIENCE
Do you or any member of your household or immediate family work for:
A market research company
An advertising agency or public relations firm
The media (TV, radio, newspapers, magazines, etc.)
As a healthcare professional who provides treatment/care to patients (doctor, nurse, pharmacist, dietician, etc.)
Have you participated in a focus group, intercept interview, telephone survey, and/or online survey in which you were asked your opinions regarding a product, a service, or advertising within the past six months? What was/were the topics discussed?
Yes
No
How many of these have you attended in the past six months? SPECIFY NUMBER
What was/were the topics discussed? SPECIFY
STANDARD DEMOGRAPHICS
Are you…(mark all that apply)
Female
Male
Transgender, non-binary, or another gender
Prefer not to answer
What sex were you assigned at birth, on your original birth certificate?
Female
Male
How do you currently describe yourself (mark all that apply)?
Female
Male
Transgender
I use a different term SPECIFY
Just to confirm, you were assigned [FILL] at birth and now you describe yourself as [FILL]. Is that correct?
Yes
No RETURN TO PREVIOUS QUESTIONS TO CORRECT
In what year were you born?
SPECIFY YEAR OF BIRTH
Prefer not to answer
In what state do you live? DROP DOWN LIST OF 50 STATES AND DC
What is your ZIP code? SPECIFY
What is the highest level of education you have completed?
Less than high school graduate
High school graduate or completed GED
Technical or vocational degree
Four-year college degree
Postgraduate or professional degree
Other SPECIFY
What best describes your current employment status?
Employed full time
Employed part time
Not employed
Homemaker
Stay-at-home parent
Student
Retired
Other SPECIFY
Prefer not to answer
What is your current job title? What term would you use to describe your current profession? SPECIFY
Please describe the type of work or industry in which you are employed. SPECIFY
Which of the following best describes your industry of employment?
Academia
Advertising/Marketing/PR/News media
Agriculture
Architecture and Engineering
Arts, Design, Entertainment, Sports, and Media
Community and Social Service
Consumer packaged goods
Education - Higher Education
Education - Primary/Secondary Education
Energy and natural resources
Entertainment/Media/Publishing
Farming, Fishing, Forestry
Financial services/Insurance
Food Services
Government and Public Administration
Health Care Support
Healthcare/Pharmaceuticals/Biotechnology
Veterinary Care
Hospitality/Travel/Tourism
Industrial/Manufacturing
Management consulting (non-financial professional/business services)
Office and Administrative Support
Retail
Sales and Customer Service
Telecommunications/IT/Technology
Transportation
Utilities
Other SPECIFY
Prefer not to say
Do you currently work as [SPECIFIC JOB OR ROLE]?
Yes
No
About how many hours per week do you work in [SPECIFIC JOB OR ROLE]? SPECIFY NUMERIC HOURS
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Prefer not to answer
Race (select all that apply):
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Prefer not to answer
IF ASIAN By background or origin, are you…? Select all that apply.
Asian Indian
Bangladeshi
Bhutanese
Burmese
Cambodian
Chinese
Filipino
Hmong
Indonesian
Japanese
Korean
Laotian
Malaysian
Mongolian
Nepalese
Okinawan
Pakistani
Sri Lankan
Taiwanese
Thai
Vietnamese
Other Asian SPECIFY
Prefer not to say
What is your marital status?
Single, never been married
Living with partner
Married
Separated
Divorced
Widowed
Prefer not to answer
Which of the following categories best describe your total annual household income?
Under $25,000/year
$25,000 - $49,999/year
$50,000 - $74,999/year
$75,000 - $99,999/year
$100,000 or more/year
Prefer not to answer
Which of the following best describes the area where you live?
Urban
Suburban
Rural
Including yourself, how many people live in your home?
One (live alone)
Two
Three
Four
Five or more
Do you currently rent or own your home?
Yes, I own my home
Yes, I rent my home
No, I live in a home but do not own or rent it
Which of the following best describes the type of place where you live now?
Apartment or condominium
Assisted living facility or nursing home
I stay in the homes of many different people as they allow me to
Emergency or homeless shelter
Tent that I set up where I can
Semi-permanent tent-like structure (e.g., yurt)
House
Mobile home or RV
Tiny home
Car
Temporary lodging, such as a hotel or motel
Something else SPECIFY
Prefer not to say
CHILDREN IN HOUSEHOLD
Are you the parent or main/primary caregiver responsible for at least one child under the age of 18?
Yes
No
How many children under age 18 live in your home? SPECIFY
What are the ages of your children under age 18 living in the household? SPECIFY FOR EACH CHILD
Are you the person who takes your child to the doctor/is primarily responsible for taking your child to medical appointments?
Yes
No
PREGNANCY
Are you currently pregnant or planning to become pregnant in the next year?
No
Not sure
Yes, I am planning on getting pregnant in the next year
Yes, I am currently pregnant
Prefer not to answer
Which trimester of pregnancy are you in?
1st trimester
2nd trimester
3rd trimester
Prefer not to answer
Is this pregnancy your first pregnancy?
Yes
No
Do you have any friends or family who are pregnant?
Yes
No
Not sure
33. Do you live with or care for someone who is pregnant?
Yes
No
SEXUAL IDENTITY & ACTIVITY
The questions in this section are used to identify groups that are sometimes at particular risk for certain health conditions or outbreaks. These questions have been used by research firms including KRC and have been approved by CDC for inclusion in prior screening questionnaires.
Are you sexually active?
Yes
No or not sure
Do you currently have sex with people who are biologically [FEMALE/MALE]?
Yes
No
Refused
Which of the following do you consider yourself to be? You can select as many as apply.
Gay or lesbian
Straight, that is not gay or lesbian
Bisexual
I use a different term SPECIFY
I don’t know
Within the past six months, have you had unprotected sex? By “unprotected sex” we mean having sex without a condom, dental dam, or glove, for example.
Yes
No
Refused
Within the past six months, have you had sex with more than one partner?
Yes
No
[For those who answer yes to sex with more than one partner] Within the past six months, how many partners have you had sex with?
HEALTH CONDITIONS
Are you living with a chronic health condition like [TOPIC]? If so, please specify. SPECIFY
Are you living with a condition that affects/compromises your immune system like [TOPIC]? If so, please specify. SPECIFY
Are you currently providing care to or supporting anyone with [CONDITION]?
Are you currently providing care to or supporting a family member in a nursing home?
Are you currently providing care to or supporting a family member on dialysis?
Have you ever been told by a healthcare professional you have any of these health conditions? Select all that apply.
Asthma
Diabetes
Emphysema/COPD/lung disease
Heart disease
High blood pressure
Cancer
Autoimmune condition/disorder
[OTHER CONDITION]
Other SPECIFY
None of the these
Prefer not to say
Have you ever been tested for [CONDITION]?
Yes
No
Not sure
Prefer not to say
Have you ever been tested for [CONDITION] in a laboratory or healthcare setting (e.g., [INSERT EXAMPLE])?
Yes
No
Not sure
Prefer not to say
Have you ever tested yourself for [CONDITION] with an over-the-counter test (e.g., [INSERT EXAMPLE])?
Yes
No
Not sure
Prefer not to say
Have you been diagnosed with [CONDITION]?
Yes
No
Not sure
Prefer not to say
Do you currently have [CONDITION]?
Yes
No
Not sure
Prefer not to say
Do you have [CONDITION] diagnosed by [SIGN, SYMPTOM, OR TEST]?
Yes
No
Not sure
Prefer not to say
For how long have you had [CONDITION]? SPECIFY LENGTH OF TIME
When were you first diagnosed with [CONDITION]? SPECIFY YEAR
Did you receive treatment for your [CONDITION]?
Yes
No
Not sure
Prefer not to say
Do you experience or are you still experiencing symptoms of [CONDITION]?
Yes
No
Not sure
Prefer not to say
Are you currently managing [CONDITION]?
Yes
No
Not sure
Prefer not to say
How well are you currently managing the effects of [CONDITION]?
1 – totally unable to manage
2
3
4
5
6
7
8
9
10 – completely able to manage
How much does your [CONDITION] affect your life?
1 – no effect at all
2
3
4
5
6
7
8
9
10 – severely affects my life
How much control do you feel you have over your [CONDITION]?
1 – absolutely no control
2
3
4
5
6
7
8
9
10 – extreme amount of control
How often do you experience symptoms from your [CONDITION]?
1 – never
2
3
4
5
6
7
8
9
10 – constantly
How severe are symptoms from your [CONDITION]?
1 – no symptoms
2
3
4
5
6
7
8
9
10 – extremely severe
What type of symptoms do you experience (or are you still experiencing)?
[LIST OF SYMPTOMS]
Before your most recent [episode / diagnosis / case / symptom expression / experience / exposure], had you ever been diagnosed with [CONDITION] previously?
Yes
No
Not sure
Prefer not to say
Has anyone in your household been diagnosed with [CONDITION]?
Yes
No
Not sure
Prefer not to say
Has a [family member, friend, or colleague of yours] been diagnosed with [CONDITION]?
Has a [family member, friend, or colleague of yours] been hospitalized with [CONDITION]?
Yes
No
Not sure
Prefer not to say
Has a [family member, friend, or colleague of yours] died from [CONDITION]?
Yes
No
Not sure
Prefer not to say
How dangerous do you think [CONDITION] would be for you personally?
Not at all dangerous
Not very dangerous
Somewhat dangerous
Very dangerous
Not sure
How dangerous do you think [CONDITION] is for the average person in the United States?
Not at all dangerous
Not very dangerous
Somewhat dangerous
Very dangerous
Not sure
How serious of a problem is [CONDITION] in the United States currently?
Not at all serious
Not very serious
Somewhat serious
Very serious
Not sure
Have you been vaccinated against [CONDITION]? If you’re not sure, just say so.
Yes
No
Not sure
Prefer not to say
Which best describes your plans/intentions to get vaccinated against [CONDITION]?
I will probably get vaccinated, but have not yet
I am still deciding whether or not I will get vaccinated
I am not going to get vaccinated
Prefer not to say
Have the children in your household been vaccinated for [CONDITION]? If you’re not sure, just say so.
Yes
No
Not sure
Prefer not to say
Which best describes your intentions to get the children in your household vaccinated against [CONDITION]?
They will probably get vaccinated, but have not yet
I am still deciding whether or not they will get vaccinated
They are not going to get vaccinated
Have you ever been tested for [CONDITION]? If you’re not sure, just say so.
Yes
No
Not sure
Prefer not to say
Have the children in your household ever been tested for [CONDITION]? If you’re not sure, just say so.
Yes
No
Not sure
Prefer not to say
Have you ever received or are you currently receiving dialysis?
Yes, currently
Yes, only in the past
No
Not sure
Prefer not to say
DOCTOR VISITS
Do you currently have a [TYPE OF HEALTHCARE PROVIDER] that you see regularly, either in-person or virtually, for routine check-ups and annual exams and other preventive health issues?
Yes
No
Not sure
Do the children in your household currently have a [TYPE OF HEALTHCARE PROVIDER] that they see regularly, either in-person or virtually, for routine check-ups and annual exams and other preventative health issues?
Yes
No
Not sure
When was the last time [YOU or YOUR CHILD] saw a [TYPE OF HEALTHCARE PROVIDER]?
Within the last 6 months
Within the last year
Within the last 2 years
More than 2 years ago
Not sure
When was the last time [YOU or YOUR CHILD] saw a [TYPE OF HEALTHCARE PROVIDER] for a [TYPE OF EXAM]?
Within the last 6 months
Within the last year
Within the last 2 years
More than 2 years ago
Not sure
In the past year, how many times [HAVE YOU or HAS YOUR CHILD] participated in a telehealth (virtual) appointment with a [TYPE OF HEALTHCARE PROVIDER]? SPECIFY NUMBER
In the past year, how many times [HAVE YOU or HAS YOUR CHILD] participated in an urgent care appointment with a [TYPE OF HEALTHCARE PROVIDER]? SPECIFY NUMBER
HEALTH INSURANCE
Do you currently have health insurance coverage that covers routine health care? By routine care, I mean [INSERT ROUTINE CARE EXAMPLES FOR CONDITION].
Yes
No
Not sure
Which one of the following best describes your primary health plan?
Insurance through a current or former employer
Insurance purchased directly from an insurance company
Insurance purchased through healthcare.gov or a state health insurance exchange
Insurance purchased through a college or university
Medicare
Medicaid
Tricare or Tricare for Life
Indian Health Care
Veterans’ Administration or VA healthcare
Some other kind of insurance SPECIFY
Prefer not to say
Don’t know
COUNTRY OF ORIGIN, TRAVEL, AND IMMIGRATION
In what country were you born?
[DISPLAY LIST OF COUNTRIES]
Do you live full-time in the United States (i.e. you spend more than half of the year in the U.S.)?
Yes
No
Prefer not to say
How long have you lived in the United States?
Less than 1 year
2-3 years
4-5 years
6-9 years
10-14 years
15-19 years
20 years or more
What is your current residency status? As a reminder, this and all other answers are confidential and will not be shared outside of the research team.
United States citizen
Permanent resident (green card holder)
Temporary resident or visitor (visa holder)
None of these
Prefer not to say
Have you ever traveled outside of the United States? If so, when was the last time?
Yes, within a year
Yes, 1-5 years ago
Yes, 6-10 years ago
Yes, more than 10 years ago
No
Prefer not to say
Have you recently traveled to [AREA NAME SUCH AS U.S. REGION] that had [DIFFERENT ECOLOGICAL CONTEXT SUCH AS DIFFERENT SOIL, WATER, INSECTS, ANIMALS]?
Yes
No
Prefer not to say
Have you ever traveled to [COUNTRY, STATE, OR REGION]?
Yes
No
Prefer not to say
When was the last time you traveled to [COUNTRY, STATE, OR REGION]?
Within 1 month
1-3 months ago
4-6 months ago
7-11 months ago
1-2 years ago
3-5 years ago
Prefer not to say
Has anyone in your household (excluding yourself) ever traveled to [COUNTRY, STATE, OR REGION]? Select all that apply.
Yes, a child
Yes, a partner or spouse
Yes, another adult
Prefer not to say
When was the last time the [child, partner or spouse, other adult] in your household traveled to [COUNTRY, STATE, OR REGION]?
Within 1 month
1-3 months ago
4-6 months ago
7-11 months ago
1-2 years ago
3-5 years ago
Prefer not to say
Do you travel between the United States and [“any one specific country” or INSERT COUNTRY] more than once a year?
Yes
No
Which country (or countries) do you travel to more than once a year? SPECIFY
How often do you travel between the United States and [COUNTRY] in an average year?
Once or twice a year
Three to four times a year
Five to ten times a year
More than ten times a year
Prefer not to say
Do you plan to travel to [COUNTRY, STATE, OR REGION] in the future? If so, when?
Yes, within a few months
Yes, within a year
Yes, in a year or more
Yes, but not sure when
No
Not sure
Prefer not to say
How often do you travel, either within or outside the United States in an average year?
No travel
Once or twice a year
Three to four times a year
Five to ten times a year
More than ten times a year
Prefer not to say
Do you plan to travel, either within or outside the United States in the next year?
Yes
No
Not sure
Where do you plan to travel in the next year? SPECIFY
What mode of transportation will you most likely use to travel to [COUNTRY, STATE, OR REGION]?
Plane
Cruise ship
Other boat
Bus (ride)
Train
Car or personal automobile
Not sure
Do you work in a role where you import goods to the United States from other countries, or have you imported goods for profit or business in the past?
Yes
No
What category of goods do you import, or have you imported, as part of your role or job? Please be specific. SPECIFY
LANGUAGE
How well do you speak English?
Very well
Fairly well
Not well
Not at all
Do you speak fluent…?
[DISPLAY LANGUAGES]
Which language do you prefer to speak at home?
[INSERT LANGUAGES SPOKEN]
About how many hours per week do you watch, listen to, or read information in the media in [INSERT LANGUAGES]? Media includes things such as TV, radio, newspapers, magazines, social media, and websites.
Less than 5 hours per week
5-9 hours per week
10-14 hours per week
15-20 hours per week
21+ hours per week
Most of the discussion will involve speaking and reading in English. Are you comfortable with speaking and reading in English?
Yes
N o
Do you feel comfortable reading the news in [INSERT LANGUAGE]?
Yes
N o
Prefer not to answer
PET OWNERSHIP
Which of the following types of pets are present at your home? Select all that apply.
Amphibian, like a frog
Bird
Cat
Dog
Fish
Rabbit
Reptile, like a snakes or lizard
Rodent, like a mouse or hamster
Other SPECIFY
None of these
Do you or others in your household own or keep any [“PETS” OR SPECIFIC ANIMAL] at your home?
Yes
No
Is the [“PET” OR SPECIFIC ANIMAL] at your home mainly your responsibility, or someone else’s?
Mainly my responsibility
Mainly someone else’s responsibility
Shared responsibility
Think about your [OLDEST/YOUNGEST] [“PET” OR SPECIFIC ANIMAL], how long have you had this [“PET” OR SPECIFIC ANIMAL]?
Less than a year
1-2 years
3-4 years
5-10 years
More than 10 years
How many [“PETS” OR SPECIFIC ANIMAL] do you currently have?
One
Two
Three
Four
More than four
Do you own, keep, or raise any of the following types of animals? Select any that apply.
Bees
Birds
Cattle
Chicken(s)
Duck(s)
Fish
Goat(s)
Geese
Horse(s), donkey(s), mule(s)
Pig(s)
Sheep
Turkey(s)
Other SPECIFY
None of these
What type of birds do you own, keep, or raise? SPECIFY
Do you regularly interact with any of the following types of animals as part of your work or as part of a hobby? Select any that apply.
[LIST OF ANIMALS, DRAWN FROM PREVIOUS QUESTIONS]
For each animal, check one:
At work
At hobby
No interactions
ADDITIONAL OCCUPATIONS & BEHAVIORS
Do you ever use the internet for health information?
Yes
No
How often do you use each of the following?
Discord
Facebook
Instagram
LinkedIn
Pinterest
Reddit
Telegram
Tiktok
Tumblr
Twitter
WeChat
Weibo
WhatsApp
YouTube
Scale
Several times a day
Once a day
Several times a week
Once a week
Less than once a week
Never
IF EVER LOG IN How often do you post or comment on each of the following?
Discord
Facebook
Instagram
LinkedIn
Pinterest
Reddit
Telegram
Tiktok
Tumblr
Twitter
WeChat
Weibo
WhatsApp
YouTube
Scale
Several times a day
Once a day
Several times a week
Once a week
Less than once a week
Never
How often do you watch, listen to, or read each of the following?
Cable, satellite, or over-air TV
Live streaming TV
On-demand streaming services like Netflix, Hulu, or Disney+
Podcasts
Magazines (print or digital)
Newspapers (print or digital)
Traditional radio (over-air or streaming)
Audio streaming services, like SiriusXM, Spotify, or Pandora
Scale
Several times a day
Once a day
Several times a week
Once a week
Less than once a week
Never
How closely do you follow news and current events these days?
Very closely
Somewhat closely
Not too closely
Not closely at all
How much interest do you have in news about the following topics?
Education
Health and healthcare
Science
Politics
Environment
Scale
A great deal of interest
Moderate interest
Limited interest
No interest
Which of the following are the primary ways you get your news these days? Select only your top [NUMBER OF SOURCES SUITABLE FOR SCREENING] sources of news.
Cable news, like FOX, CNN, MSNBC
Network news, like CBS, NBC, ABC
Newspapers, like New York Times, Wall Street Journal (print or online)
Internet news services, like Apple News, Google News
Radio programming
Blogs
Podcasts
News magazines, like Economist, Time, National Review (print or online)
Other online-only news, like Huffington Post, Vox, Daily Caller
Conversation or word of mouth from people I know
Something else SPECIFY
None of these
Where do you work most of the time?
Mainly work indoors
Mainly work outdoors
Travel to different buildings or sites
In a motor vehicle
Somewhere else
Varies
Do you work in or at [WORK SETTING TYPE]?
Yes
No
Do you handle or prepare food as part of your job?
Yes
No
Do you work with agricultural products as part of your job?
Yes
No
Do you do any of the following activities in the course of an average year? Select one response per activity.
Hunting
Fishing
Harvesting shellfish
Gathering mushrooms
Gathering wild fruit, vegetables, roots, or berries
[OTHER WILD FOOD SOURCE]
Boating (sailing, kayaking, powerboating, etc.)
Swimming in a pool (pool)
Swimming in natural bodies of water like lakes, ocean, etc.
Hiking
Trail running
Camping
Wilderness trekking or survival experiences
Mountain biking
Rock climbing
Exploring caves
Birdwatching
Gardening activities that involve digging up dirt and soil
Riding all-terrain vehicles not on defined roads
Visiting farms or other places like fairs and rodeos to interact with animals
Visiting farms to pick fruits or vegetables
[OTHER NATURAL RECREATION ACTIVITY]
Scale for each
Yes
No
How often do you [ACTIVITY FROM PREVIOUS]?
Less than once a year
About once a year
A few times a year
Several times a year
Regularly
Do you ever participate in outdoor recreation activities or hobbies? If so, please share them here. SPECIFY
QUESTIONS FOR HEALTHCARE PROVIDERS
In what primary state are you licensed to practice your role in medicine?
[DROP-DOWN LIST OF 50 STATES AND DC]
What is the ZIP code of the primary state where you are licensed to practice your role medicine?
[ENTER ZIP; DISPLAY ERROR MESSAGE IF ZIP CODE ENTERED DOES NOT MATCH STATE]
Which of the following best describes the practice or setting where you work?
Urban
Suburban
Small town
Rural
Are you a:
MD (Doctor of Medicine)
DO (Doctor of Osteopathic Medicine)
Physician Assistant/Physician Associate
Nurse
Medical Assistant
EMS worker
Dentist
Pharmacist
Physiotherapist
Podiatrist
Optometrist
Veterinarian
[OTHER AS NEEDED]
Prefer not to say
None of these
Which of the following comes closest to your professional nursing title?
Licensed Practical Nurse
Registered Nurse
Advanced Practice Nurse
Clinical Research Nurse
Another type of nurse SPECIFY
Prefer not to say
IF MD OR DO PA OR NP Are you in primary care or specialty care?
Primary care
Specialty care
Other SPECIFY
Prefer not to say
IF PRIMARY CARE PHYSICIAN Are you a…?
Family physician
General practitioner
General Internist
Obstetrics and Gynecology (OBGYN)
Other SPECIFY
Prefer not to say
IF SPECIALIST Which best describes your primary medical specialty?
Allergy/Immunology
Anesthesiology
Cardiology
Cardiothoracic Surgery
Colorectal Surgery
Dentistry
Dermatology
Endocrinology
Gastrointestinal Medicine
General Surgery
Genetics
Geriatrics
Hematology/Oncology
Hospitalist
Hospital-Based Anesthesiology
Hospital-Based Pathology
Infectious Diseases
Locum Tenens or temporary physician employment
Med-Peds (Combined Internal Medicine & Pediatrics)
Neonatology
Nephrology
Neurology
Neurosurgery
Nuclear Medicine
Obstetrics and Gynecology (OBGYN)
Ophthalmology
Oral Surgery
Orthopedics
Otolaryngology
Pediatrics
Pharmacy
Physical Medicine and Rehabilitation
Plastic Surgery
Psychiatry/Behavioral Health
Psychology
PT/OT/ST Therapy
Pulmonary
Radiology
Rheumatology
Urology
Vascular Surgery
[INSERT OTHER AS NEEDED]
Other SPECIFY
Prefer not to say
Is your primary responsibility direct patient care?
Yes
No
Prefer not to say
What percent of your time is dedicated to adult care per week?
None or very little
Less than 25%
25% to 49%
50% or more
Prefer not to say
What percent of your time is dedicated to pediatrics per week?
None or very little
Less than 25%
25% to 49%
50% or more
Prefer not to say
Does your practice serve Medicaid patients?
Yes
No
Not sure
What proportion of your patients are on Medicaid?
Less than 5%
Between 5% and 10%
10% to 25%
25% to 50%
More than half my patients
Does your practice serve patients who are underserved, poor, and/or uninsured?
Yes
No
Not sure
What proportion of your patients are underserved, poor, and/or uninsured?
Less than 5%
Between 5% and 10%
10% to 25%
25% to 50%
More than half my patients
Does your practice serve patients who have limited English proficiency?
Yes
No
Not sure
If yes, what proportion of your patients have limited English proficiency?
Less than 5%
Between 5% and 10%
10% to 25%
25% to 50%
More than half my patients
Do you serve any of the following patient populations at your practice?
[NATIONALITY] born in [COUNTRY MATCHING NATIONALITY]
[NATIONALITY] born in [COUNTRY MATCHING NATIONALITY]
[NATIONALITY] born in [COUNTRY MATCHING NATIONALITY]
None of these
You serve [PATIENT POPULATION]. Altogether, approximately how many [PATIENT POPULATION] patients combined do you personally serve each week?
19 or fewer
20-29
30-39
40 or more
Does your practice communicate with your patients in other languages besides English? This could include language services, but also patient materials.
Yes
No
Does your practice communicate with your patients in any of the following languages?
Hindi
Tagalog
Mandarin
Vietnamese
Spanish
[INSERT OTHER AS NEEDED]
Other SPECIFY
None of these
Specifically, which communication services does your practice offer?
Bilingual or multilingual healthcare providers
Interpreters
Language lines
In-language patient education materials
[INSERT OTHER AS NEEDED]
Other SPECIFY
None of these
What year did you complete medical school? SPECIFY YEAR
What was the name of your medical school where you received your training? SPECIFY SCHOOL
In approximately what year did you complete your (first) residency that is associated with your role as a [TYPE OF HEALTHCARE PROVIDER]?
2015 or later
Between 1980 and 2014
1979 or earlier
Which best describes your practice setting?
Solo practice
Single specialty group practice
Multi-specialty group practice
Staff Model Health Maintenance Organization or HMO
Other model HMO, Managed Care Organization
Network managed care systems such as PPOs
Mixed model practice
Hospital-based practice
Indigent care facility
Publicly managed and funded clinic
Locum Tenens or temporary physician employment
[INSERT OTHER AS NEEDED]
Other SPECIFY
How many years of experience do you have in healthcare, including your training?
SPECIFY YEARS
Prefer not to say
In what setting do you primarily see your patients?
Outpatient or primary care setting
Hospital-based setting
Facility setting (e.g., including rehab facility, assisted living, or nursing home)
IF HOSPITAL-BASED SETTING Do you see fewer than 50% or 50% or more of your patients in a hospital?
Fewer than 50%
50% or more
IF HOSPITAL-BASED SETTING Is the hospital where you work…
A federal, military, or Veterans Health Administration hospital
A behavioral health hospital
A long-term care hospital
IF HOSPITAL-BASED AND MD, DO, OR NURSE Please estimate the number of beds at the hospital where you work (not the total across the hospital system).
Fewer than 25
25-99
100-499
500 or more
Prefer not to say
IF HOSPITAL-BASED AND MD, DO, OR NURSE Please select the most appropriate description of the department you work in at your hospital.
Emergency room/emergency medicine
Intensive care unit (ICU)
Anesthesiology
Oncology
Operating room (OR)
Medical surgery
Labor and delivery
Pharmacy
Ambulatory care
Urgent care
Radiology
[INSERT OTHER AS NEEDED]
Other SPECIFY
Prefer not to say
IF PRIMARY CARE SETTING Do you primarily work in a private or group practice, an HMO practice, an urgent care clinic, or something else?
Private solo practice
Group practice
HMO practice
Urgent care clinic
Specialized clinic
Community health center/clinic
[INSERT OTHER AS NEEDED]
Other SPECIFY
Are you a…?
Licensed veterinarian
Licensed veterinary technician
Veterinary assistant
None of these
Have you been trained to perform dialysis for patients?
Yes
No
Not sure
Do you currently use dialysis to treat any of your patients?
Yes
No
Not sure
NCEZID
Screening Question Bank |
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | [email protected] |
| File Modified | 0000-00-00 |
| File Created | 2025-11-23 |
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