Attachment F-2
National Survey of U.S. Public’s Awareness of Racial and Ethnic Health Disparities
Questionnaire, Physician Population
Attachment F-2
Form Approved OMB No. 0990-XXXX
Exp. Date XX/XX/XX11
NATIONAL SURVEY OF U.S. PUBLIC’S AWARENESS
OF RACIAL AND ETHNIC HEALTH DISPARITIES
Physician Population Edition
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990- . The time required to complete this information collection is estimated to average 14 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.
DIRECTIONS
Thank you for agreeing to participate in this survey.
For each question, please choose the answer that best applies to you. If you are not able to find an answer that fits exactly, choose the one that comes closest.
These questions can be answered by simply marking the box next to the response that best fits your answer.
We appreciate you taking the time to contribute to this important study.
__________________________________________________________________
These first few questions ask about your practice and public health information.
How would you describe the practice where you see most of your patients (i.e., your main practice)?
General hospital
Private practice
Teaching hospital
Local health department
Community health clinic
Campus health center
Other (Specify __________________________________________________________)
2. What percentage of your patients are (check only one percentage for each group):
Less than 10% 11- 25% 26-50% Over 50%
White
Black or African American
Hispanic/Latino
Asian American/Pacific Islander
Other (Specify_______________)
3. In the last year, have you heard or read anything about racial and ethnic disparities in health and health care in America?
Yes (If yes, briefly describe_____________________________________________)
No
________________________________________________________________________
4. Have you ever heard of any of the following public health campaigns or read any of the following publications? (Check all that apply)
The US Dept. of Health and Human Services’ Healthy People 2010
The Agency for Healthcare Research and Quality’s National Healthcare Disparities Report
The Institute of Medicine’s 2003 report, Unequal Treatment: Confronting Racial and
Ethnic Disparities in Health Care
The Office of Minority Health’s National Partnership for Action
The PBS Documentary: Unnatural Causes: Is Inequality Making Us Sick?
______________________________________________________________________
5. Does the organization where you currently practice offer the following (check all that apply):
Training for your staff using OMH’s Cultural Competency Curriculum Modules (CCCMs)
Language assistance services (i.e., bilingual staff, interpreter services)
Easily understood patient-related materials in the languages of the commonly encountered groups and/or groups represented in your service area.
Signage in the languages of the commonly encountered groups and/or groups represented in your service area.
___________________________________________________________________________
For the next few questions, please think about African Americans in our country today.
6. Do you think the average African American is better off, worse off or just as well off as the average white person in terms of:
getting needed health care?
Better off
Worse off
Just as well off
infant mortality?
Better off
Worse off
Just as well off
life expectancy?
Better off
Worse off
Just as well off
________________________________________________________________________
7. Do you think the average African American is more likely, just as likely, or less likely to be diagnosed (or to have) with any of the following health conditions as the average white person?
Auto Immune Deficiency Syndrome (AIDS) or the HIV virus
More likely
Just as likely
Less likely
Cancer (including cancer of the stomach, prostate, or bladder)
More likely
Just as likely
Less likely
Hypertension
More likely
Just as likely
Less likely
Diabetes
More likely
Just as likely
Less likely
________________________________________________________________________
8. When going to a doctor or health clinic for health care services, do you think most
African Americans receive the same quality of health care as whites, higher quality of care or lower quality of health care as most whites?
Same quality
Higher quality
Lower quality
________________________________________________________________________
9. Do you think the average African American is better off, worse off or just as well off as
the average white person in terms of:
how healthy they are?
Better off
Worse off
Just as well off
getting routine medical care when they need it?
Better off
Worse off
Just as well off
getting specialized treatments or surgery when they need it?
Better off
Worse off
Just as well off
having health insurance?
Better off
Worse off
Just as well off
________________________________________________________________________
10. How big a problem do you think each of the following issues is for the average African American? Is it a major problem, a minor problem or not a problem at all for the average African American?
a. being able to afford the cost of health insurance and necessary medical care
Major problem
Minor problem
Not a problem at all
b. having enough doctors and other health providers near where they live
Major problem
Minor problem
Not a problem at all
c. having difficulty getting care because of their race or ethnic background
Minor problem
Not a problem at all
________________________________________________________________________
Now, thinking about Hispanics or Latinos in our country today.
11. Do you think the average Hispanic/Latino is better off, worse off or just as well off as the
average white person in terms of:
getting needed health care?
Better off
Worse off
Just as well off
infant mortality?
Better off
Worse off
Just as well off
life expectancy?
Better off
Worse off
Just as well off
________________________________________________________________________
12. Do you think the average Hispanic/Latino is more likely, just as likely, or less likely to be
diagnosed (or to have) any of the following health conditions as the average white person?
Auto Immune Deficiency Syndrome (AIDS) or the HIV virus
More likely
Just as likely
Less likely
Cancer (including cancer of the stomach and liver)
More likely
Just as likely
Less likely
Hypertension
More likely
Just as likely
Less likely
Diabetes
More likely
Just as likely
Less likely
________________________________________________________________________
13. When going to a doctor or health clinic for health care services, do you think most Hispanics/Latinos receive the same quality of health care as whites, higher quality of care or lower quality of health care as most whites?
Same quality
Higher quality
Lower quality
________________________________________________________________________
14. How big a problem do you think each of the following issues is for the average Hispanic/Latino? Is it a major problem, a minor problem or not a problem at all for the average Hispanic/Latino?
a. being able to afford the cost of health insurance and necessary medical care
Major problem
Minor problem
Not a problem at all
b. having enough doctors and other health providers near where they live
Major problem
Minor problem
Not a problem at all
c. having difficulty getting care because of their race or ethnic background
Major problem
Minor problem
Not a problem at all
________________________________________________________________________
15. Do you think the average Hispanic/Latino is better off, worse off or just as well off as the average white person in terms of
how healthy they are?
Better off
Worse off
Just as well off
getting routine medical care when they need it?
Better off
Worse off
Just as well off
getting specialized treatments or surgery when they need it?
Better off
Worse off
Just as well off
having health insurance?
Better off
Worse off
Just as well off
________________________________________________________________________
Now, thinking about Asian Americans/Pacific Islanders in our country today,
16. Do you think the average Asian American/ Pacific Islander is better off, worse off or just as well off as the average white person in terms of:
getting needed health care?
Better off
Worse off
Just as well off
infant mortality?
Better off
Worse off
Just as well off
life expectancy?
Better off
Worse off
Just as well off
________________________________________________________________________
17. Do you think the average Asian American/ Pacific Islander is more likely, just as likely, or less likely to be diagnosed (or to have):
Auto Immune Deficiency Disorder (AIDS) or the HIV virus
More likely
Just as likely
Less likely
Cancer (including cancer of the stomach and liver)
More likely
Just as likely
Less likely
Hypertension
More likely
Just as likely
Less likely
Diabetes
More likely
Just as likely
Less likely
________________________________________________________________________
18. When going to the doctor or health clinic for health care services, do you think most
Asian American/ Pacific Islanders receive the same quality of health care as whites, higher quality of care or lower quality of health care as most whites?
Same quality
Higher quality
Lower quality
________________________________________________________________________
19. How big a problem do you think each of the following issues is for the average Asian American/ Pacific Islander? Is this a major problem, a minor problem or not a problem at all for the average Asian American/ Pacific Islander?
a. being able to afford the cost of health insurance and necessary medical care
Major problem
Minor problem
Not a problem at all
b. having enough doctors and other health providers near where they live
Major problem
Minor problem
Not a problem at all
c. having difficulty getting care because of their race or ethnic background
Major problem
Minor problem
Not a problem at all
________________________________________________________________________
20. Do you think the average Asian American/ Pacific Islander is better off, worse off or just as well off as the average white person in terms of:
how healthy they are?
Better off
Worse off
Just as well off
getting routine medical care when they need it?
Better off
Worse off
Just as well off
getting specialized treatments or surgery when they need it?
Better off
Worse off
Just as well off
having health insurance?
Better off
Worse off
Just as well off
________________________________________________________________________
These last questions are designed to help us better understand the doctors who participate in our survey.
21. Are you male or female?
Male
Female
________________________________________________________________________
22. What is your age?
___________
23. Are you yourself of Hispanic, Latino or Spanish origin?
Yes
No
________________________________________________________________________
24. What is your race?
Black or African American
Asian American/ Pacific Islander
Other (Specify __________________________________________________________)
_________________________________________________________________________
Thank you very much for completing the questionnaire. The information you have provided will be useful to policymakers. If you have anything else to add, or any questions, please call toll-free 1-877-236-8161. Again, thank you for your participation.
PLEASE RETURN THE COMPLETED QUESTIONNAIRE IN THE POSTAGE-PAID ENVELOPE, OR FAX THE SURVEY TO: secure fax-line.
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| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |