Form matched response matched response matched response

National Practitioner Data Bank and Healthcare Integrity and Protection Data Bank Market Survey and Survey of Use of Data Bank Information

npdb hipdb matched response

Matched Response Survey

OMB: 0915-0316

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WEB

Application ID#:

URL: https://gx.gallup.com/npdbmatched.gx

FINAL DRAFT – JUNE 7, 2007

PROJECT REGISTRATION #148998

HRSA – NPDB/HIPDB N TRANSLATIONS

City Center: Government

National Practitioner

Data Bank Matched Manager X SURVEY DESIGN: Tara McGhee

Bogart/Steiger/Dean

Scott Cook, Programmer

June, 2007 n=

(PROGRAMMER NOTE: BANNER FOR THE TOP OF EACH SCREEN)

OMB NO. 0915-XXXX

Expiration Date:

THE NATIONAL PRACTITIONER DATA BANK (NPDB)

AND

THE HEALTHCARE INTEGRITY AND PROTECTION DATA BANK (HIPDB)

MATCHED RESPONSE QUESTIONNAIRE

(PROGRAMMER NOTE: At the bottom of each screen, display:)

If you need assistance completing this survey, please contact Gallup Client Support by sending an e-mail to galluppoll@gallup.com or by calling 1-888-297-8999 from 8:00 a.m. to 8:00 p.m. Eastern Time, Monday through Thursday, or 8:00 a.m. to 6:00 p.m. Eastern Time on Fridays.

Do not print, store, or copy this page.

(PROGRAMMER NOTE: If completed survey found in database for this Access Code, display the following error message:)

A survey has already been completed with this Access Code. Thank you for your participation.

If you feel you have received this message in error, please contact Gallup Client Support at galluppoll@gallup.com or call 1-888-297-8999 for assistance.

Sa. STRATUM: (Code from Sample File)

1 Malpractice Payers

2 Licensing Boards

3 Hospitals

4 Managed Care Organizations

5 Other Health Care Entities

Sb. DATABANK LISTED ON REPORT: (Code from Sample File)

1 NPDB

2 HIPDB

3 BOTH

THE NATIONAL PRACTITIONER DATA BANK (NPDB)

AND

THE HEALTHCARE INTEGRITY AND PROTECTION DATA BANK (HIPDB)

MATCHED RESPONSE QUESTIONNAIRE

Conducted by:

The Gallup Organization

Welcome to the NPDB and HIPDB Matched Response Questionnaire.

Thank you for agreeing to participate in the NPDB-HIPDB Matched Response Questionnaire. Your answers will help improve the NPDB and HIPDB so we can better respond to your querying and reporting needs.

This questionnaire is a pre-test of the proposed instrument that is to take place in the Fall of 2007. Many changes have been made to the NPDB since our last survey in 2000. The results from that survey helped us design and implement these improvements. We anticipate that the results from this pre-test will similarly help us improve the NPDB and HIPDB.

Because you are participating in the pre-testing of this important project, your feedback on this survey is vital. Please keep track of the number of minutes it takes you to complete the survey (at the end you will be asked to report the time it took). In addition, at certain points throughout the survey, you will have the opportunity to comment on the clarity and logic of specific questions in the survey. At the end of the survey, you will be asked to provide recommendations for how to improve the survey.

Your participation in this pre-test is greatly appreciated.

This survey concerns specific NPDB-HIPDB responses and how the information in these responses was used. Up to three NPDB-HIPDB responses to your queries on individual practitioners will be identified on the next screen, after you enter your unique Access Code. The information on the next screen, like the information in NPDB reports, is confidential. It is provided for use in this survey by the NPDB-HIPDB solely to indicate the particular query response(s) you previously received. The questions in this survey pertain only to those query responses. The responses to this survey will not be identified in our records by practitioner, and The Gallup Organization has no information concerning the contents of the query responses identified on the next screen. This is being conducted on a secure Web site. If you have any questions concerning the confidentiality of this survey, please call the NPDB-HIPDB Customer Service Center at 1-800-767-6732.

If you do not complete the survey in one sitting you can log on again and the survey will resume where you left off. You will not have to repeat any of the questions you have already answered.

Public reporting burden for the applicant for this collection of information is estimated to average .25 hour per response (15 minutes), including the time for reviewing the instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to: Health Resources and Services Administration Reports Clearance Officer, 5600 Fishers Lane, Room 14-33, Rockville, Maryland 20857.

To begin, please enter your unique Access Code that was printed in your e-mail invitation and click the "Begin Survey" button to continue.

Access Code: (Fill in response)

(PROGRAMMER NOTE: If Invalid Access Code is entered, display the following error message:)

You must enter a valid Access Code to continue.

(PROGRAMMER NOTE: If No Access Code is entered, display the following error message:)

You must enter an Access Code to continue.

The questions that follow pertain to the response(s) you received from [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB] on the practitioner(s) identified below. Please find the report(s) in your files and answer all questions in reference to these specific report(s).

When you have the reports in hand, please mark off the practitioners below for whom you were able to locate reports. If you are unable to locate a report, we may request your feedback on an additional report.

PRACTITIONER #1

Name of Practitioner: (Code from sample file)

Date of Query Response: (Code from sample file)

Control Number: (Code from sample file)

PRACTITIONER #2

Name of Practitioner: (Code from sample file)

Date of Query Response: (Code from sample file)

Control Number: (Code from sample file)

PRACTITIONER #3

Name of Practitioner: (Code from sample file)

Date of Query Response: (Code from sample file)

Control Number: (Code from sample file)

When you have the report(s) in hand, please click "Next" to begin the survey. You may log out and log back in if needed.

<Next>

For each of these reports, you will be asked to provide dates of the events surrounding the query, the sources that were consulted in reviewing the practitioner’s application, the usage and usefulness of the information contained in the report, and the status of your action concerning this practitioner.

If you are not sure about the answer to a particular question, please consult with others to identify the answer. You may print out the pages containing questions where you need help, gather the responses, and log back on to see the pages you left blank.

(PROGRAMMER NOTE: Display at the top of each screen)

PRACTITIONER #1: (NAME FROM SAMPLE FILE, QUERY RESPONSE DATE FROM SAMPLE FILE)

2-1. Which of the following reasons BEST describes why your entity queried the [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB] for this practitioner? (PROGRAMMER NOTE: If code 1, 3, 4, or 5 in Sa, display codes 1-2 and 6; If code 2 in Sa, display codes 3, 4, 5, and 6)

1 Recredentialing/Reprivileging

2 New credentialing/privileging application

3 Initial licensure

4 Reinstatement of license

5 Renewal of license

6 Disciplinary investigation

(Error Message:)

A response is required to continue.

(If code 1 in #2-1, Continue;

If code 2 in #2-1, Skip to #4-1;

If codes 3-5 in #2-1, Skip to #4a-1;

Otherwise, Skip to #5-1)

3-1. Please provide dates for each of the following events regarding this practitioner’s recredentialing/ reprivileging application, using MM/DD/YY format (for example, 02/23/99).

a. Year practitioner privileges first granted (Fill in response) (Allow 6 digits) (MM/DD/YY)

b. Date of query that led to the matched response (Fill in response) (Allow 6 digits) (MM/DD/YY)

c. (Autofill with information from sample file) Date of query response

d. Date of preliminary decision about recredentialing/reprivileging (Fill in response) (Allow 6 digits) (MM/DD/YY)

1 No preliminary decision was made or the matter is still pending. (PROGRAMMER NOTE: Make this a check box)

e. Date of final decision about recredentialing/reprivileging (Fill in response) (Allow 6 digits) (MM/DD/YY)

1 No final decision was made or the matter is still pending. (PROGRAMMER NOTE: Make this a check box)

(If invalid date entered for #3-1 a-e, display the following error message:)

You have entered an invalid date. Please re-enter.

(Error Message:)

Please enter numbers only.

(All in #3-1, Skip to #6x-1)

4-1. Please provide dates for each of the following events regarding this practitioner’s new credentialing/ privileging application, using MM/DD/YY format (for example, 02/23/99).

a. Date of application for privileges (Fill in response) (Allow 6 digits) (MM/DD/YY)

b. Date of query (Fill in response) (Allow 6 digits) (MM/DD/YY)

c. (Autofill with information from sample file) Date of query response

d. Date of initial decision on privileges (Fill in response) (Allow 6 digits) (MM/DD/YY)

1 No initial decision was made or the matter is still pending. (PROGRAMMER NOTE: Make this a check box)

e. Date of final decision (Fill in response) (Allow 6 digits) (MM/DD/YY)

1 No final decision was made or the matter is still pending. (PROGRAMMER NOTE: Make this a check box)

(If invalid date entered for #4-1 a-e, display the following error message:)

You have entered an invalid date. Please re-enter.

(Error Message:)

Please enter numbers only.

(All in #4-1, Skip to #6x-1)

4a-1. Please provide dates for each of the following events regarding this practitioner’s application, using MM/DD/YY format (for example, 02/23/99).

a. Year practitioner applied for license reinstatement or renewal (Fill in response) (Allow 6 digits) (MM/DD/YY)

b. Date of query that led to this response (Fill in response) (Allow 6 digits) (MM/DD/YY)

c. (Autofill with information from sample file) Date of query response

d. Date of preliminary decision about licensure, reinstatement, or renewal (Fill in response) (Allow 6 digits) (MM/DD/YY)

1 No preliminary decision was made or the matter is still pending. (PROGRAMMER NOTE: Make this a check box)

e. Date of final decision about licensure, reinstatement, or renewal (Fill in response) (Allow 6 digits) (MM/DD/YY)

1 No final decision was made or the matter is still pending. (PROGRAMMER NOTE: Make this a check box)

(If invalid date entered for $4a-1 a-e, display the following error message:)

You have entered an invalid date. Please re-enter.

(Error Message:)

Please enter numbers only.

(All in #4a-1, Skip to #6x-1)

5-1. Please provide dates for each of the following events regarding this practitioner’s disciplinary investigation, using MM/DD/YY format (for example, 02/23/99).

a. Date investigation began (Fill in response) (Allow 6 digits) (MM/DD/YY)

b. Date of query (Fill in response) (Allow 6 digits) (MM/DD/YY)

c. (Autofill with information from sample file) Date of query response

d. Date of initial decision on disciplinary action (Fill in response) (Allow 6 digits) (MM/DD/YY)

1 No initial decision was made or the matter is still pending. (PROGRAMMER NOTE: Make this a check box)

e. Date of final decision on disciplinary action (Fill in response) (Allow 6 digits) (MM/DD/YY)

1 No final decision was made or the matter is still pending. (PROGRAMMER NOTE: Make this a check box)

(If invalid date entered for #5-1 a-e, display the following error message:)

You have entered an invalid date. Please re-enter.

(Error Message:)

Please enter numbers only.

6x-1. How easy or difficult was it for you to answer the previous questions?

1 Very difficult

5 Very easy

For the next set of questions, please use the following terminology note:

RESPONSE is the umbrella term for what you receive from the Data Banks when you query.

REPORT, used as a noun, is the term for information submitted concerning each reportable malpractice payment or adverse action.

Unless a practitioner has never been reported, a RESPONSE from the Data Banks contains one or more REPORTS, each of which concerns a specific malpractice payment or adverse action, as filed by reporting entities, such as malpractice insurers, hospitals, licensing boards, etc., concerning the practitioner queried on.

6-1. Did this response contain any new information that you hadn’t learned from previous [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB] queries or from other sources?

1 Yes

2 No

(If code 1 in #6-1, Continue;

Otherwise, Skip to #7-1)

6a-1. If you had queried previously on this practitioner, does this response include any new reports that were not contained in previous [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB] responses?

1 Yes

2 No

3 Not applicable, had not queried previously on this practitioner

(If code 1 in #6a-1, Continue;

Otherwise, Skip to #7-1)

6b-1. How many individual reports did you receive in this response? (Fill in response) (Allow 2 digits)

(Error Message:)

Please enter numbers only.

6c-1. How many of these individual reports contained in this [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB] response provided new information? (Fill in response) (Allow 2 digits)

(Error Message:)

Please enter numbers only.

7-1. In addition to [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB], did you consult any of the following sources of information in reviewing this practitioner’s application? (Display a-q)

7-1. (Continued:)

2 No

q. Other

1 Yes

2 No

(If code 1 in #7-1q, Continue;

Otherwise, Skip to Note before #8a-1)

7-1q1. What other source of information in reviewing this practitioner’s application did you consult? (Fill in response) (Allow 200 characters)

(If code 1 to ANY in #7-1 a-q, Continue;

Otherwise, Skip to #10-1)

8a-1. Did any of these additional sources identify adverse actions or medical malpractice payments that were not listed in the [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB] response?

1 Yes

2 No

(If code 1 in #8a-1, Continue;

Otherwise, Skip to #9a-1)

(There is no question #8b-1)

8c-1. How many of each of the following actions not listed in the [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB] response were identified by these additional sources? (Click all that apply)

0 None (PROGRAMMER NOTE: Make this a check box)

1 Malpractice payments after September 1, 1990

2 Clinical privileges after September 1, 1990

3 Licensing actions after September 1, 1990

4 Professional society membership actions after September 1, 1990

5 Medicare/Medicaid exclusion reports after September 1, 1990

6 Health care related civil judgments after 8/21/96

7 Criminal convictions after 8/21/96

8 Health plan contract actions after 8/21/96

9a-1. Did any of the sources below report information that conflicted with the information you received in the [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB] response? (Display a-q, as appropriate)

a. (If code 1 in #7-1-a, ask:) Board Action Data Bank of the Federation of State Medical Boards (FSMB)

1 Yes

2 No

b. (If code 1 in #7-1-b, ask:) National organization(s) of state licensing boards for non-physician practitioners

1 Yes

2 No

9a-1. (Continued:)

c. (If code 1 in #7-1-c, ask:) Licensing board(s) in your STATE

1 Yes

2 No

d. (If code 1 in #7-1-d, ask:) Licensing board(s) in another state

1 Yes

2 No

e. (If code 1 in #7-1-e, ask:) Practitioner’s current medical malpractice insurance carrier(s)

1 Yes

2 No

f. (If code 1 in #7-1-f, ask:) Practitioner’s previous medical malpractice insurance carrier(s)

1 Yes

2 No

g. (If code 1 in #7-1-g, ask:) Practitioner’s current affiliated health plan(s)

1 Yes

2 No

h. (If code 1 in #7-1-h, ask:) Practitioner’s previous affiliated health plan(s)

1 Yes

2 No

i. (If code 1 in #7-1-i, ask:) Hospital(s)

1 Yes

2 No

9a-1. (Continued:)

j. (If code 1 in #7-1-j, ask:) Other health care entities (HMOs, group practices, etc.)

1 Yes

2 No

k. (If code 1 in #7-1-k, ask:) Professional society(ies)

1 Yes

2 No

l. (If code 1 in #7-1-l, ask:) Medical school(s)

1 Yes

2 No

m. (If code 1 in #7-1-m, ask:) Other professional school(s)

1 Yes

2 No

n. (If code 1 in #7-1-n, ask:) Residency program(s)

1 Yes

2 No

o. (If code 1 in #7-1-o, ask:) American Medical Association (AMA)

1 Yes

2 No

p. (If code 1 in #7-1-p, ask:) American Board of Medical Specialties (ABMS)

1 Yes

2 No

q. Other (Fill in response) (Allow 100 characters)

(If code 1 to ANY in #9a-1 a-p

or if verbatim entered for #9a-1q, Continue;

Otherwise, Skip to #10-1)

9b-1. Did you make additional inquiries to obtain more detailed information to resolve the conflict?

1 Yes

2 No

(If code 1 in #9b-1, Continue;

Otherwise, Skip to #10-1)

9c-1. Did your additional inquiries show the [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB] response to be accurate, inaccurate, or was it not possible to tell?

1 NPDB/HIPDB response accurate

2 NPDB/HIPDB response inaccurate

f. Committee of the board

1 Yes

2 No

3 Don’t know

g. Medical staff committee

1 Yes

2 No

3 Don’t know

h. Board subcommittee

1 Yes

2 No

3 Don’t know

i. Full board

1 Yes

2 No

3 Don’t know

j. Internal staff

1 Yes

2 No

3 Don’t know

k. Board Executive Director

1 Yes

2 No

3 Don’t know

l. Other board management staff

1 Yes

Otherwise, Skip to #13a-1)

11-1. What is the status of your action concerning this practitioner?

1 Privileges renewed as requested

2 Privileges suspended pending further investigation

3 Privileges restricted or amended but not revoked

4 Privileges revoked

5 Action pending

6 Application withdrawn by practitioner with no action taken

(If code 1, 5, or 6 in #11-1, Skip to #16-1;

If code 2 or 3 in #11-1, Skip to #14-1;

If code 4 in #11-1, Skip to #15-1;

If No Response in #11-1, Skip to #16-1)

12-1. What is the status of your action concerning this practitioner?

1 Privileges granted as requested

2 Restricted privileges granted

3 Privileges denied

4 Action pending

5 Application withdrawn by practitioner with no action taken

(If code 1, 4, or 5 in #12-1, Skip to #16-1;

If code 2 in #12-1, Skip to #14-1;

If code 3 in #12-1, Skip to #15-1;

If No Response in #12-1, Skip to #16-1)

13-1. What is the status of your action concerning this practitioner?

1 Privileges reinstated

2 Privileges restricted for less than 30 days

3 Privileges restricted for 30 days or more

4 Privileges revoked

5 Other corrective action

6 Action pending

7 No adverse action taken

8 Practitioner resigned during investigation; no action taken

(If code 1, 4, 5, or 8 in #13-1, Skip to #15-1;

If code 2 or 3 in #13-1, Skip to #14-1;

If code 6 or 7 in #13-1, Skip to #16-1;

If No Response in #13-1, Skip to #16-1)

13a-1. What is the status of your action concerning this practitioner?

1 Licensure/reinstatement/renewal granted as requested

2 Restricted or limited license granted

3 New licensure/Renewal/Reinstatement denied

4 Action pending

5 Withdrawn by practitioner with no action taken

(If code 1, 3, 4, or 5 in #13a-1, Skip to #16-1;

If code 2 in #13a-1, Skip to #14a-1;

If No Response in #13a-1, Skip to #16-1)

13b-1. What is the status of your action concerning this practitioner?

1 License restricted or limited

2 Licensee reprimanded or censured

3 Licensee put on probation

4 License suspended

5 License revoked

6 Other corrective action

7 Action pending

8 No adverse action taken

9 Practitioner surrendered license during investigation

(If code 1-6 in #13b-1, Skip to #14a-1;

If code 7 or 8 in #13b-1, Skip to #16-1;

If code 9 in #13b-1, Skip to #15a-1;

If No Response in #13b-1, Skip to #16-1)

14-1. In which of the following ways were privileges restricted or suspended? (Click all that apply)

1 All privileges suspended

2 May not perform certain procedures

3 Mandatory consultation (but not approval) required for treating certain conditions or performing certain procedures

4 May perform certain procedures only with the PRIOR approval of or participation by another practitioner

5 Mandatory approval of admissions OR discharges by another practitioner

6 Proctor assigned to review practitioner’s work after the fact

7 Other (Fill in response) (Allow 100 characters)

(All in #14-1, Skip to #15-1)

14a-1. Under which of the following conditions was licensure granted? (Click all that apply)

1 Additional education required

2 Probationary period

3 Required supervision/monitoring

4 Limited areas of practice

5 Other (Fill in response) (Allow 100 characters)

15-1. Has the action you have taken regarding this practitioner (or the practitioner’s resignation while under investigation) been reported to the [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB]?

1 Yes

2 No, report pending

3 No, a reportable action was not taken

(All in #15-1, Skip to #16-1)

15a-1. Has this practitioner’s surrender of license during investigation been reported to the [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB]?

1 Yes

2 No, report is pending

3 No

16-1. Overall, would you say that the information contained in the [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB] response on this practitioner was useful to you?

1 Yes

2 No

(If code 1 in #16-1, Continue;

Otherwise, Skip to #18-1)

17-1. Which of the following best explains why you found the response useful? (Click all that apply)

1 NPDB/HIPDB is our basic source for malpractice payment, licensure, clinical privileges, and exclusion information

2 The response included information not received from other sources

3 The response confirmed other sources of information

4 The response confirmed information from the practitioner’s application

5 The response served as a "flag" to identify the need for further investigation

6 The response helped us judge provider’s competency

7 The response helped us judge provider’s professional conduct

8 Other (Fill in response) (Allow 100 characters)

(All in #17-1, Skip to #19-1)

18-1. Which of the following best explains why you did not find the response useful? (Click all that apply)

1 Information available elsewhere

2 Information did not help us judge provider’s professional competence or conduct

3 Information was inaccurate

4 Information too old to be useful

5 Information was not received in a timely fashion

6 Other (Fill in response) (Allow 100 characters)

19-1. Regardless of the action taken with this practitioner, how influential was the information you received from [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB] in your decision?

1 Not at all influential

7 Very influential

8 No action taken yet

(If code 1-7 in #19-1, Continue;

Otherwise, Skip to Note after #21-1)

20-1. Would your decision regarding the practitioner have been different if you had not received the [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB] response?

1 Yes

2 No

3 Don’t know

(If code 3 in #20-1, Skip to Note after #21-1;

Otherwise, Continue)

21-1. Please explain why your decision would or would not have been different without the [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB] response. (Fill in response) (Allow 300 characters)

(If Response in PRACTITIONER #2, Continue;

Otherwise, Skip to Text before #22x)

Thank you for completing the Matched Response Questionnaire for Practitioner #1. Next, please answer the same set of questions for Practitioner #2.

(PROGRAMMER NOTE: APPEAR AT TOP OF EACH SCREEN)

PRACTITIONER #2: (NAME FROM SAMPLE FILE, QUERY RESPONSE DATE FROM SAMPLE FILE)

2-2. Which of the following reasons BEST describes why your entity queried the [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB] for this practitioner? (PROGRAMMER NOTE: If code 1, 3, 4, or 5 in Sa, display codes 1-2 and 6; If code 2 in Sa, display codes 3, 4, 5, and 6)

1 Recredentialing/Reprivileging

2 New credentialing/privileging application

3 Initial licensure

4 Reinstatement of license

5 Renewal of license

6 Disciplinary investigation

(Error Message:)

A response is required to continue.

(If code 1 in #2-2, Continue;

If code 2 in #2-2, Skip to #4-2;

If codes 3-5 in #2-2, Skip to #4a-2;

Otherwise, Skip to #5-2)

3-2. Please provide dates for each of the following events regarding this practitioner’s recredentialing/reprivileging application, using MM/DD/YY format (for example, 02/23/99).

a. Year practitioner privileges first granted (Fill in response) (Allow 6 digits) (MM/DD/YY)

b. Date of query that led to the matched response (Fill in response) (Allow 6 digits) (MM/DD/YY)

c. (Autofill with information from sample file) Date of query response

d. Date of preliminary decision about recredentialing/reprivileging (Fill in response) (Allow 6 digits) (MM/DD/YY)

1 No preliminary decision was made or the matter is still pending. (PROGRAMMER NOTE: Make this a check box)

e. Date of final decision about recredentialing/reprivileging (Fill in response) (Allow 6 digits) (MM/DD/YY)

1 No final decision was made or the matter is still pending. (PROGRAMMER NOTE: Make this a check box)

(If invalid date entered for #3-2 a-e, display the following error message:)

You have entered an invalid date. Please re-enter.

(Error Message:)

Please enter numbers only.

(All in #3-2, Skip to #6x-2)

4-2. Please provide dates for each of the following events regarding this practitioner’s new credentialing/ privileging application, using MM/DD/YY format (for example, 02/23/99).

a. Date of application for privileges (Fill in response) (Allow 6 digits) (MM/DD/YY)

b. Date of query (Fill in response) (Allow 6 digits) (MM/DD/YY)

c. (Autofill with information from sample file) Date of query response

d. Date of initial decision on privileges (Fill in response) (Allow 6 digits) (MM/DD/YY)

1 No initial decision was made or the matter is still pending. (PROGRAMMER NOTE: Make this a check box)

e. Date of final decision (Fill in response) (Allow 6 digits) (MM/DD/YY)

1 No final decision was made or the matter is still pending. (PROGRAMMER NOTE: Make this a check box)

(If invalid date entered for #4-2 a-e, display the following error message:)

You have entered an invalid date. Please re-enter.

(Error Message:)

Please enter numbers only.

(All in #4-2, Skip to #6x-2)

4a-2. Please provide dates for each of the following events regarding this practitioner’s application, using MM/DD/YY format (for example, 02/23/99).

a. Year practitioner applied for license reinstatement or renewal (Fill in response) (Allow 6 digits) (MM/DD/YY)

b. Date of query that led to this response (Fill in response) (Allow 6 digits) (MM/DD/YY)

c. (Autofill with information from sample file) Date of query response

d. Date of preliminary decision about licensure, reinstatement, or renewal (Fill in response) (Allow 6 digits) (MM/DD/YY)

1 No preliminary decision was made or the matter is still pending. (PROGRAMMER NOTE: Make this a check box)

e. Date of final decision about licensure, reinstatement, or renewal (Fill in response) (Allow 6 digits) (MM/DD/YY)

1 No final decision was made or the matter is still pending. (PROGRAMMER NOTE: Make this a check box)

(If invalid date entered for #4a-2 a-e, display the following error message:)

You have entered an invalid date. Please re-enter.

(Error Message:)

Please enter numbers only.

(All in #4a-2, Skip to #6x-2)

5-2. Please provide dates for each of the following events regarding this practitioner’s disciplinary investigation, using MM/DD/YY format (for example, 02/23/99).

a. Date investigation began (Fill in response) (Allow 6 digits) (MM/DD/YY)

b. Date of query (Fill in response) (Allow 6 digits) (MM/DD/YY)

c. (Autofill with information from sample file) Date of query response

d. Date of initial decision on disciplinary action (Fill in response) (Allow 6 digits) (MM/DD/YY)

1 No initial decision was made or the matter is still pending. (PROGRAMMER NOTE: Make this a check box)

e. Date of final decision on disciplinary action (Fill in response) (Allow 6 digits) (MM/DD/YY)

1 No final decision was made or the matter is still pending. (PROGRAMMER NOTE: Make this a check box)

(If invalid date entered for #5-2 a-e, display the following error message:)

You have entered an invalid date. Please re-enter.

(Error Message:)

Please enter numbers only.

6x-2. How easy or difficult was it for you to answer the previous questions?

1 Very difficult

5 Very easy

For the next set of questions, please use the following terminology note:

RESPONSE is the umbrella term for what you receive from the Data Banks when you query.

REPORT, used as a noun, is the term for information submitted concerning each reportable malpractice payment or adverse action.

6-2. Did this response contain any new information that you hadn’t learned from previous [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB] queries or from other sources?

1 Yes

2 No

(If code 1 in #6-2, Continue;

Otherwise, Skip to #7-2)

6a-2. If you had queried previously on this practitioner, does this response include any new reports that were not contained in previous [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB] responses?

1 Yes

2 No

3 Not applicable, had not queried previously on this practitioner

(If code 1 in #6a-2, Continue;

Otherwise, Skip to #7-2)

6b-2. How many individual reports did you receive in this response? (Fill in response) (Allow 2 digits)

(Error Message:)

Please enter numbers only.

6c-2. How many of these individual reports contained in this [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB] response provided new information? (Fill in response) (Allow 2 digits)

(Error Message:)

Please enter numbers only.

7-2. In addition to [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB], did you consult any of the following sources of information in reviewing this practitioner’s application? (Display a-q)

7-2. (Continued:)

2 No

q. Other

1 Yes

2 No

(If code 1 in #7-2q, Continue;

Otherwise, Skip to Note before #8a-2)

7-2q1. What other source of information in reviewing this practitioner’s application did you consult? (Fill in response) (Allow 200 characters)

(If code 1 to ANY in #7-2 a-q, Continue;

Otherwise, Skip to #10-2)

8a-2. Did any of these additional sources identify adverse actions or medical malpractice payments that were not listed in the [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB] response?

1 Yes

2 No

(If code 1 in #8a-2, Continue;

Otherwise, Skip to #9a-2)

(There is no question #8b-2)

8c-2. How many of each of the following actions not listed in the [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB] response were identified by these additional sources? (Click all that apply)

0 None (PROGRAMMER NOTE: Make this a check box)

1 Malpractice payments after September 1, 1990

2 Clinical privileges after September 1, 1990

3 Licensing actions after September 1, 1990

4 Professional society membership actions after September 1, 1990

5 Medicare/Medicaid exclusion reports after September 1, 1990

6 Health care related civil judgments after 8/21/96

7 Criminal convictions after 8/21/96

8 Health plan contract actions after 8/21/96

9a-2. Did any of the sources below report information that conflicted with the information you received in the [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB] response? (Display a-q, as appropriate)

a. (If code 1 in #7-2-a, ask:) Board Action Data Bank of the Federation of State Medical Boards (FSMB)

1 Yes

2 No

b. (If code 1 in #7-2-b, ask:) National organization(s) of state licensing boards for non-physician practitioners

1 Yes

2 No

9a-2. (Continued:)

c. (If code 1 in #7-2-c, ask:) Licensing board(s) in your STATE

1 Yes

2 No

d. (If code 1 in #7-2-d, ask:) Licensing board(s) in another state

1 Yes

2 No

e. (If code 1 in #7-2-e, ask:) Practitioner’s current medical malpractice insurance carrier(s)

1 Yes

2 No

f. (If code 1 in #7-2-f, ask:) Practitioner’s previous medical malpractice insurance carrier(s)

1 Yes

2 No

g. (If code 1 in #7-2-g, ask:) Practitioner’s current affiliated health plan(s)

1 Yes

2 No

h. (If code 1 in #7-2-h, ask:) Practitioner’s previous affiliated health plan(s)

1 Yes

2 No

i. (If code 1 in #7-2-i, ask:) Hospital(s)

1 Yes

2 No

9a-2. (Continued:)

j. (If code 1 in #7-2-j, ask:) Other health care entities (HMOs, group practices, etc.)

1 Yes

2 No

k. (If code 1 in #7-2-k, ask:) Professional society(ies)

1 Yes

2 No

l. (If code 1 in #7-2-l, ask:) Medical school(s)

1 Yes

2 No

m. (If code 1 in #7-2-m, ask:) Other professional school(s)

1 Yes

2 No

n. (If code 1 in #7-2-n, ask:) Residency program(s)

1 Yes

2 No

o. (If code 1 in #7-2-o, ask:) American Medical Association (AMA)

1 Yes

2 No

p. (If code 1 in #7-2-p, ask:) American Board of Medical Specialties (ABMS)

1 Yes

2 No

q. Other (Fill in response) (Allow 100 characters)

(If code 1 to ANY in #9a-2 a-p

or if verbatim entered for #9a-2q, Continue;

Otherwise, Skip to #10-2)

9b-2. Did you make additional inquiries to obtain more detailed information to resolve the conflict?

1 Yes

2 No

(If code 1 in #9b-2, Continue;

Otherwise, Skip to #10-2)

9c-2. Did your additional inquiries show the [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB] response to be accurate, inaccurate, or was it not possible to tell?

1 NPDB/HIPDB response accurate

2 NPDB/HIPDB response inaccurate

f. Committee of the board

1 Yes

2 No

3 Don’t know

g. Medical staff committee

1 Yes

2 No

3 Don’t know

h. Board subcommittee

1 Yes

2 No

3 Don’t know

i. Full board

1 Yes

2 No

3 Don’t know

j. Internal staff

1 Yes

2 No

3 Don’t know

k. Board Executive Director

1 Yes

2 No

3 Don’t know

l. Other board management staff

1 Yes

Otherwise, Skip to #13a-2)

11-2. What is the status of your action concerning this practitioner?

1 Privileges renewed as requested

2 Privileges suspended pending further investigation

3 Privileges restricted or amended but not revoked

4 Privileges revoked

5 Action pending

6 Application withdrawn by practitioner with no action taken

(If code 1, 5, or 6 in #11-2, Skip to #16-2;

If code 2 or 3 in #11-2, Skip to #14-2;

If code 4 in #11-2, Skip to #15-2;

If No Response in #11-2, Skip to #16-2)

12-2. What is the status of your action concerning this practitioner?

1 Privileges granted as requested

2 Restricted privileges granted

3 Privileges denied

4 Action pending

5 Application withdrawn by practitioner with no action taken

(If code 1, 4, or 5 in #12-2, Skip to #16-2;

If code 2 in #12-2, Skip to #14-2;

If code 3 in #12-2, Skip to #15-2;

If No Response in #12-2, Skip to #16-2)

13-2. What is the status of your action concerning this practitioner?

1 Privileges reinstated

2 Privileges restricted for less than 30 days

3 Privileges restricted for 30 days or more

4 Privileges revoked

5 Other corrective action

6 Action pending

7 No adverse action taken

8 Practitioner resigned during investigation; no action taken

(If code 1, 4, 5, or 8 in #13-2, Skip to #15-2;

If code 2 or 3 in #13-2, Skip to #14-2;

If code 6 or 7 in #13-2, Skip to #16-2;

If No Response in #13-2, Skip to #16-2)

13a-2. What is the status of your action concerning this practitioner?

1 Licensure/reinstatement/renewal granted as requested

2 Restricted or limited license granted

3 New licensure/Renewal/Reinstatement denied

4 Action pending

5 Withdrawn by practitioner with no action taken

(If code 1, 3, 4, or 5 in #13a-2, Skip to #16-2;

If code 2 in #13a-2, Skip to #14a-2;

If No Response in #13a-2, Skip to #16-2)

13b-2. What is the status of your action concerning this practitioner?

1 License restricted or limited

2 Licensee reprimanded or censured

3 Licensee put on probation

4 License suspended

5 License revoked

6 Other corrective action

7 Action pending

8 No adverse action taken

9 Practitioner surrendered license during investigation

(If code 1-6 in #13b-2, Skip to #14a-2;

If code 7 or 8 in #13b-2, Skip to #16-2;

If code 9 in #13b-2, Skip to #15a-2;

If No Response in #13b-2, Skip to #16-2)

14-2. In which of the following ways were privileges restricted or suspended? (Click all that apply)

1 All privileges suspended

2 May not perform certain procedures

3 Mandatory consultation (but not approval) required for treating certain conditions or performing certain procedures

4 May perform certain procedures only with the PRIOR approval of or participation by another practitioner

5 Mandatory approval of admissions OR discharges by another practitioner

6 Proctor assigned to review practitioner’s work after the fact

7 Other (Fill in response) (Allow 100 characters)

(All in #14-2, Skip to #15-2)

14a-2. Under which of the following conditions was licensure granted? (Click all that apply)

1 Additional education required

2 Probationary period

3 Required supervision/monitoring

4 Limited areas of practice

5 Other (Fill in response) (Allow 100 characters)

15-2. Has the action you have taken regarding this practitioner (or the practitioner’s resignation while under investigation) been reported to the [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB]?

1 Yes

2 No, report pending

3 No, a reportable action was not taken

(All in #15-2, Skip to #16-2)

15a-2. Has this practitioner’s surrender of license during investigation been reported to the [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB]?

1 Yes

2 No, report is pending

3 No

16-2. Overall, would you say that the information contained in the [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB] response on this practitioner was useful to you?

1 Yes

2 No

(If code 1 in #16-2, Continue;

Otherwise, Skip to #18-2)

17-2. Which of the following best explains why you found the response useful? (Click all that apply)

1 NPDB/HIPDB is our basic source for malpractice payment, licensure, clinical privileges, and exclusion information

2 The response included information not received from other sources

3 The response confirmed other sources of information

4 The response confirmed information from the practitioner’s application

5 The response served as a "flag" to identify the need for further investigation

6 The response helped us judge provider’s competency

7 The response helped us judge provider’s professional conduct

8 Other (Fill in response) (Allow 100 characters)

(All in #17-2, Skip to #19-2)

18-2. Which of the following best explains why you did not find the response useful? (Click all that apply)

1 Information available elsewhere

2 Information did not help us judge provider’s professional competence or conduct

3 Information was inaccurate

4 Information too old to be useful

5 Information was not received in a timely fashion

6 Other (Fill in response) (Allow 100 characters)

19-2. Regardless of the action taken with this practitioner, how influential was the information you received from [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB] in your decision?

1 Not at all influential

7 Very influential

8 No action taken yet

(If code 1-7 in #19-2, Continue;

Otherwise, Skip to Note after #21-2)

20-2. Would your decision regarding the practitioner have been different if you had not received the [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB] response?

1 Yes

2 No

3 Don’t know

(If code 3 in #20-2, Skip to Note after #21-2;

Otherwise, Continue)

21-2. Please explain why your decision would or would not have been different without the [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB] response. (Fill in response) (Allow 300 characters)

(If Response in PRACTITIONER #3, Continue;

Otherwise, Skip to Text before #22x)

Thank you for completing the Matched Response Questionnaire for Practitioner #2. Next, please answer the same set of questions for Practitioner #3.

(PROGRAMMER NOTE: APPEAR AT TOP OF EACH SCREEN)

PRACTITIONER #3: (NAME FROM SAMPLE FILE, QUERY RESPONSE DATE FROM SAMPLE FILE)

2-3. Which of the following reasons BEST describes why your entity queried the [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB] for this practitioner? (PROGRAMMER NOTE: If code 1, 3, 4, or 5 in Sa, display codes 1-2 and 6; If code 2 in Sa, display codes 3, 4, 5, and 6)

1 Recredentialing/Reprivileging

2 New credentialing/privileging application

3 Initial licensure

4 Reinstatement of license

5 Renewal of license

6 Disciplinary investigation

(Error Message:)

A response is required to continue.

(If code 1 in #2-3, Continue;

If code 2 in #2-3, Skip to #4-3;

If codes 3-5 in #2-3, Skip to #4a-3;

Otherwise, Skip to #5-3)

3-3. Please provide dates for each of the following events regarding this practitioner’s recredentialing/reprivileging application, using MM/DD/YY format (for example, 02/23/99).

a. Year practitioner privileges first granted (Fill in response) (Allow 6 digits) (MM/DD/YY)

b. Date of query that led to the matched response (Fill in response) (Allow 6 digits) (MM/DD/YY)

c. (Autofill with information from sample file) Date of query response

d. Date of preliminary decision about recredentialing/reprivileging (Fill in response) (Allow 6 digits) (MM/DD/YY)

1 No preliminary decision was made or the matter is still pending. (PROGRAMMER NOTE: Make this a check box)

e. Date of final decision about recredentialing/reprivileging (Fill in response) (Allow 6 digits) (MM/DD/YY)

1 No final decision was made or the matter is still pending. (PROGRAMMER NOTE: Make this a check box)

(If invalid date entered for #3-3 a-e, display the following error message:)

You have entered an invalid date. Please re-enter.

(Error Message:)

Please enter numbers only.

(All in #3-3, Skip to #6x-3)

4-3. Please provide dates for each of the following events regarding this practitioner’s new credentialing/ privileging application, using MM/DD/YY format (for example, 02/23/99).

a. Date of application for privileges (Fill in response) (Allow 6 digits) (MM/DD/YY)

b. Date of query (Fill in response) (Allow 6 digits) (MM/DD/YY)

c. (Autofill with information from sample file) Date of query response

d. Date of initial decision on privileges (Fill in response) (Allow 6 digits) (MM/DD/YY)

1 No initial decision was made or the matter is still pending. (PROGRAMMER NOTE: Make this a check box)

e. Date of final decision (Fill in response) (Allow 6 digits) (MM/DD/YY)

1 No final decision was made or the matter is still pending. (PROGRAMMER NOTE: Make this a check box)

(If invalid date entered for #4-3 a-e, display the following error message:)

You have entered an invalid date. Please re-enter.

(Error Message:)

Please enter numbers only.

(All in #4-3, Skip to #6x-3)

4a-3. Please provide dates for each of the following events regarding this practitioner’s application, using MM/DD/YY format (for example, 02/23/99).

a. Year practitioner applied for license reinstatement or renewal (Fill in response) (Allow 6 digits) (MM/DD/YY)

b. Date of query that led to this response (Fill in response) (Allow 6 digits) (MM/DD/YY)

c. (Autofill with information from sample file) Date of query response

d. Date of preliminary decision about licensure, reinstatement, or renewal (Fill in response) (Allow 6 digits) (MM/DD/YY)

1 No preliminary decision was made or the matter is still pending. (PROGRAMMER NOTE: Make this a check box)

e. Date of final decision about licensure, reinstatement, or renewal (Fill in response) (Allow 6 digits) (MM/DD/YY)

1 No final decision was made or the matter is still pending. (PROGRAMMER NOTE: Make this a check box)

(If invalid date entered for #4a-3 a-e, display the following error message:)

You have entered an invalid date. Please re-enter.

(Error Message:)

Please enter numbers only.

(All in #4a-3, Skip to #6x-3)

5-3. Please provide dates for each of the following events regarding this practitioner’s disciplinary investigation, using MM/DD/YY format (for example, 02/23/99).

a. Date investigation began (Fill in response) (Allow 6 digits) (MM/DD/YY)

b. Date of query (Fill in response) (Allow 6 digits) (MM/DD/YY)

c. (Autofill with information from sample file) Date of query response

d. Date of initial decision on disciplinary action (Fill in response) (Allow 6 digits) (MM/DD/YY)

1 No initial decision was made or the matter is still pending. (PROGRAMMER NOTE: Make this a check box)

e. Date of final decision on disciplinary action (Fill in response) (Allow 6 digits) (MM/DD/YY)

1 No final decision was made or the matter is still pending. (PROGRAMMER NOTE: Make this a check box)

(If invalid date entered for #5-3 a-e, display the following error message:)

You have entered an invalid date. Please re-enter.

(Error Message:)

Please enter numbers only.

6x-3. How easy or difficult was it for you to answer the previous questions?

1 Very difficult

5 Very easy

For the next set of questions, please use the following terminology note:

RESPONSE is the umbrella term for what you receive from the Data Banks when you query.

REPORT, used as a noun, is the term for information submitted concerning each reportable malpractice payment or adverse action.

6-3. Did this response contain any new information that you hadn’t learned from previous [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB] queries or from other sources?

1 Yes

2 No

(If code 1 in #6-3, Continue;

Otherwise, Skip to #7-3)

6a-3. If you had queried previously on this practitioner, does this response include any new reports that were not contained in previous [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB] responses?

1 Yes

2 No

3 Not applicable, had not queried previously on this practitioner

(If code 1 in #6a-3, Continue;

Otherwise, Skip to #7-3)

6b-3. How many individual reports did you receive in this response? (Fill in response) (Allow 2 digits)

(Error Message:)

Please enter numbers only.

6c-3. How many of these individual reports contained in this [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB] response provided new information? (Fill in response) (Allow 2 digits)

(Error Message:)

Please enter numbers only.

7-3. In addition to [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB], did you consult any of the following sources of information in reviewing this practitioner’s application? (Display a-q)

7-3. (Continued:)

2 No

q. Other

1 Yes

2 No

(If code 1 in #7-3q, Continue;

Otherwise, Skip to Note before #8a-3)

7-3q1. What other source of information in reviewing this practitioner’s application did you consult? (Fill in response) (Allow 200 characters)

(If code 1 to ANY in #7-3 a-q, Continue;

Otherwise, Skip to #10-3)

8a-3. Did any of these additional sources identify adverse actions or medical malpractice payments that were not listed in the [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB] response?

1 Yes

2 No

(If code 1 in #8a-3, Continue;

Otherwise, Skip to #9a-3)

(There is no question #8b-3)

8c-3. How many of each of the following actions not listed in the [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB] response were identified by these additional sources? (Click all that apply)

0 None (PROGRAMMER NOTE: Make this a check box)

1 Malpractice payments after September 1, 1990

2 Clinical privileges after September 1, 1990

3 Licensing actions after September 1, 1990

4 Professional society membership actions after September 1, 1990

5 Medicare/Medicaid exclusion reports after September 1, 1990

6 Health care related civil judgments after 8/21/96

7 Criminal convictions after 8/21/96

8 Health plan contract actions after 8/21/96

9a-3. Did any of the sources below report information that conflicted with the information you received in the [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB] response? (Display a-q, as appropriate)

a. (If code 1 in #7-3-a, ask:) Board Action Data Bank of the Federation of State Medical Boards (FSMB)

1 Yes

2 No

b. (If code 1 in #7-3-b, ask:) National organization(s) of state licensing boards for non-physician practitioners

1 Yes

2 No

9a-3. (Continued:)

c. (If code 1 in #7-3-c, ask:) Licensing board(s) in your STATE

1 Yes

2 No

d. (If code 1 in #7-3-d, ask:) Licensing board(s) in another state

1 Yes

2 No

e. (If code 1 in #7-3-e, ask:) Practitioner’s current medical malpractice insurance carrier(s)

1 Yes

2 No

f. (If code 1 in #7-3-f, ask:) Practitioner’s previous medical malpractice insurance carrier(s)

1 Yes

2 No

g. (If code 1 in #7-3-g, ask:) Practitioner’s current affiliated health plan(s)

1 Yes

2 No

h. (If code 1 in #7-3-h, ask:) Practitioner’s previous affiliated health plan(s)

1 Yes

2 No

i. (If code 1 in #7-3-i, ask:) Hospital(s)

1 Yes

2 No

9a-3. (Continued:)

j. (If code 1 in #7-3-j, ask:) Other health care entities (HMOs, group practices, etc.)

1 Yes

2 No

k. (If code 1 in #7-3-k, ask:) Professional society(ies)

1 Yes

2 No

l. (If code 1 in #7-3-l, ask:) Medical school(s)

1 Yes

2 No

m. (If code 1 in #7-3-m, ask:) Other professional school(s)

1 Yes

2 No

n. (If code 1 in #7-3-n, ask:) Residency program(s)

1 Yes

2 No

o. (If code 1 in #7-3-o, ask:) American Medical Association (AMA)

1 Yes

2 No

p. (If code 1 in #7-3-p, ask:) American Board of Medical Specialties (ABMS)

1 Yes

2 No

q. Other (Fill in response) (Allow 100 characters)

(If code 1 to ANY in #9a-3 a-p

or if verbatim entered for #9a-3q, Continue;

Otherwise, Skip to #10-3)

9b-3. Did you make additional inquiries to obtain more detailed information to resolve the conflict?

1 Yes

2 No

(If code 1 in #9b-3, Continue;

Otherwise, Skip to #10-3)

9c-3. Did your additional inquiries show the [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB] response to be accurate, inaccurate, or was it not possible to tell?

1 NPDB/HIPDB response accurate

2 NPDB/HIPDB response inaccurate

f. Committee of the board

1 Yes

2 No

3 Don’t know

g. Medical staff committee

1 Yes

2 No

3 Don’t know

h. Board subcommittee

1 Yes

2 No

3 Don’t know

i. Full board

1 Yes

2 No

3 Don’t know

j. Internal staff

1 Yes

2 No

3 Don’t know

k. Board Executive Director

1 Yes

2 No

3 Don’t know

l. Other board management staff

1 Yes

Otherwise, Skip to #13a-3)

11-3. What is the status of your action concerning this practitioner?

1 Privileges renewed as requested

2 Privileges suspended pending further investigation

3 Privileges restricted or amended but not revoked

4 Privileges revoked

5 Action pending

6 Application withdrawn by practitioner with no action taken

(If code 1, 5, or 6 in #11-3, Skip to #16-3;

If code 2 or 3 in #11-3, Skip to #14-3;

If code 4 in #11-3, Skip to #15-3;

If No Response in #11-3, Skip to #16-3)

12-3. What is the status of your action concerning this practitioner?

1 Privileges granted as requested

2 Restricted privileges granted

3 Privileges denied

4 Action pending

5 Application withdrawn by practitioner with no action taken

(If code 1, 4, or 5 in #12-3, Skip to #16-3;

If code 2 in #12-3, Skip to #14-3;

If code 3 in #12-3, Skip to #15-3;

If No Response in #12-3, Skip to #16-3)

13-3. What is the status of your action concerning this practitioner?

1 Privileges reinstated

2 Privileges restricted for less than 30 days

3 Privileges restricted for 30 days or more

4 Privileges revoked

5 Other corrective action

6 Action pending

7 No adverse action taken

8 Practitioner resigned during investigation; no action taken

(If code 1, 4, 5, or 8 in #13-3, Skip to #15-3;

If code 2 or 3 in #13-3, Skip to #14-3;

If code 6 or 7 in #13-3, Skip to #16-3;

If No Response in #13-3, Skip to #16-3)

13a-3. What is the status of your action concerning this practitioner?

1 Licensure/reinstatement/renewal granted as requested

2 Restricted or limited license granted

3 New licensure/Renewal/Reinstatement denied

4 Action pending

5 Withdrawn by practitioner with no action taken

(If code 1, 3, 4, or 5 in #13a-3, Skip to #16-3;

If code 2 in #13a-3, Skip to #14a-3;

If No Response in #13a-3, Skip to #16-3)

13b-3. What is the status of your action concerning this practitioner?

1 License restricted or limited

2 Licensee reprimanded or censured

3 Licensee put on probation

4 License suspended

5 License revoked

6 Other corrective action

7 Action pending

8 No adverse action taken

9 Practitioner surrendered license during investigation

(If code 1-6 in #13b-3, Skip to #14a-3;

If code 7 or 8 in #13b-3, Skip to #16-3;

If code 9 in #13b-3, Skip to #15a-3;

If No Response in #13b-3, Skip to #16-3)

14-3. In which of the following ways were privileges restricted or suspended? (Click all that apply)

1 All privileges suspended

2 May not perform certain procedures

3 Mandatory consultation (but not approval) required for treating certain conditions or performing certain procedures

4 May perform certain procedures only with the PRIOR approval of or participation by another practitioner

5 Mandatory approval of admissions OR discharges by another practitioner

6 Proctor assigned to review practitioner’s work after the fact

7 Other (Fill in response) (Allow 100 characters)

(All in #14-3, Skip to #15-3)

14a-3. Under which of the following conditions was licensure granted? (Click all that apply)

1 Additional education required

2 Probationary period

3 Required supervision/monitoring

4 Limited areas of practice

5 Other (Fill in response) (Allow 100 characters)

15-3. Has the action you have taken regarding this practitioner (or the practitioner’s resignation while under investigation) been reported to the [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB]?

1 Yes

2 No, report pending

3 No, a reportable action was not taken

(All in #15-3, Skip to #16-3)

15a-3. Has this practitioner’s surrender of license during investigation been reported to the [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB]?

1 Yes

2 No, report is pending

3 No

16-3. Overall, would you say that the information contained in the [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB] response on this practitioner was useful to you?

1 Yes

2 No

(If code 1 in #16-3, Continue;

Otherwise, Skip to #18-3)

17-3. Which of the following best explains why you found the response useful? (Click all that apply)

1 NPDB/HIPDB is our basic source for malpractice payment, licensure, clinical privileges, and exclusion information

2 The response included information not received from other sources

3 The response confirmed other sources of information

4 The response confirmed information from the practitioner’s application

5 The response served as a "flag" to identify the need for further investigation

6 The response helped us judge provider’s competency

7 The response helped us judge provider’s professional conduct

8 Other (Fill in response) (Allow 100 characters)

(All in #17-3, Skip to #19-3)

18-3. Which of the following best explains why you did not find the response useful? (Click all that apply)

1 Information available elsewhere

2 Information did not help us judge provider’s professional competence or conduct

3 Information was inaccurate

4 Information too old to be useful

5 Information was not received in a timely fashion

6 Other (Fill in response) (Allow 100 characters)

19-3. Regardless of the action taken with this practitioner, how influential was the information you received from [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB] in your decision?

1 Not at all influential

7 Very influential

8 No action taken yet

(If code 1-7 in #19-3, Continue;

Otherwise, Skip to Note after #21-3)

20-3. Would your decision regarding the practitioner have been different if you had not received the [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB] response?

1 Yes

2 No

3 Don’t know

(If code 3 in #20-3, Skip to Text before #22x;

Otherwise, Continue)

21-3. Please explain why your decision would or would not have been different without the [(If code 1 in S1, display:) NPDB/(If code 2 in S1, display:) HIPDB/(If code 3 in S1, display:) NPDB/HIPDB] response. (Fill in response) (Allow 300 characters)

(PROGRAMMER NOTE: Right above the "Submit Survey" button, display:)

Thank you for participating in the NPDB/HIPDB Matched Response Survey. Please submit your survey by clicking the "Submit Survey" button below. Once you click on this button, you will no longer have access to these survey responses.

You may now close your browser or go to another Web page.

jlw\Dept_of_Health_Human_Services\Questionnaires\WEB\2007\

HRSA Practitioner Matching WEB 0705

DHHS-HRSA MATCHING WEB 02/05/21

File Type	application/msword
Author	Gallup
Last Modified By	HRSA
File Modified	2007-10-04
File Created	2007-10-04