2.2 Survey

OMB #: 0925-0593

OMB Expiration Date: 07/31/ 2013

Provider Based Sampling Frame Questionnaire Jefferson County, Phase 2e

Provider Based Sampling Frame Questionnaire

(Jefferson County)

Event:	Provider Based Recruitment
Participant: Respondent:	Provider Provider
Domain:	Questionnaire
Type of Document: Allowable Mode: Allowable Method:	Self-Administered Questionnaire In Person, Telephone, Mail PAPI
Recruitment Groups:	PBS
Version:	1.0
Release:	MDES 3.0

Provider-Based Sampling Frame Questionnaire

DEFINITIONS:

• Practice Location/Office: The physical site where the patient care services are delivered; is staffed by one or more health care providers.

• Provider: A licensed clinician (e.g., physician, nurse, mid-wife, etc) who provides prenatal health care services at one or more locations within the practice.

1. For Office Use Only:

PSU ID # (Jefferson County): 20000223

Practice #: 

Location #: 

2. Date Questionnaire is completed:  /  / 

M M / D D / Y Y Y Y

3. Name of practice (This could be the doctor’s name, the clinic name, the practice name, etc.)

__________________________________________________________________________________

4. Address of practice location/office:

Street Address: ______________________________________________________________________

Suite/Unit#: ______________________________________________________________________

City: ______________________________________________________________________

State:  Zip Code:  - 

5. Name and contact information for practice location/office contact person:

Name: ______________________________________________________________________

Position/Role: ______________________________________________________________________

Street Address: ______________________________________________________________________

Suite/Unit#: ______________________________________________________________________

City: ______________________________________________________________________

State:  Zip Code:  - 

Email Address: ______________________________________________________________________

Phone Number: ()  -  Ext: 

Preferred method of contact: ____________________________________________

6. Total number of providers of prenatal care at location/office:

 Total providers

7. Practice location/office provider mix (number of each provider type):

(The total number of providers listed below should equal the number of total providers in Question #6.)

 Number of Obstetrics/Gynecology (OB/GYN) providers

 Number of Obstetrics (OB) providers only

 Number of Gynecology (GYN) providers only

 Number of Family Medicine Providers (that provide prenatal care)

 Number of Midwives

 Number of Other Providers. (such as Nurse Practitioners)

Other (Specify): _____________________________________________________________

8. Type of practice:

 Private with no health system or university affiliation

 Private with health system or university affiliation

 Health system with no university affiliation

 Academic medical center

 Federally qualified health center

 Public clinic with no university/academic affiliation

 Public clinic with university/academic affiliation

 Other. (Specify): ________________________________________________________

For Questions #9 through #11 below, if you do not have precise numbers, please provide your best estimates.

9. In 2011, or the last year for which you have 12 months of complete data, what was the number of all prenatal care visits across all providers within this location/office?

 All prenatal care visits

10. In 2011, or the last year for which you have 12 months of complete data, what was the number of first prenatal care visits across all providers within this location/office? (This number is a subset of the total visits listed in Question #9.)

 First prenatal care visits

11. In 2011, or the last year for which you have 12 months of complete data, what was the number of first prenatal care visits across all providers within this location/office of patients who reside in Jefferson county? (This number is a subset of the first prenatal care visits listed in Question #10.)

 First prenatal care visits of Jefferson county residents

12. Approximate payer mix:

For the list of payers that follows, regarding the approximate payer mix for this practice location/office, list the percent for each payer. Please provide an estimate if the exact percent is not known. The total percentage for all payers cannot be greater than 100%.

Tricare: %

Medicaid: %

Commercial: %

HMO: %

Self Pay: %

13. Observed or reported ethnicity of first prenatal care visits:

For the first prenatal care visit patients at this medical practice location/office, please indicate the percent of those patients with the following observed or reported ethnicity . Please provide an estimate if the exact percent is not known.

Hispanic, Latina, or Spanish origin %

14. Observed or reported primary race of first prenatal care visit patients:

Using the following categories, list the observed or reported primary race of patients at this medical practice location/office. Again, the focus is on patients seen at the first prenatal care visit. Please provide an estimate if the exact percent is not known. The total percentage for all races cannot be greater than 100%.

White: %

Black or African American: %

American Indian or Alaska Native: %

Asian: %

Native Hawaiian/ other Pacific Islander: %

15. Observed or reported primary language preferred by first prenatal care visit patients, by percent:

Using the following options, indicate the reported primary language of first prenatal care visit patients at this medical practice location/office. Please estimate if the exact percent is not known. The total percentage for all languages cannot be greater than 100%.

English: %

Spanish: %

Other: %

(If other, Specify:) __________________________________________________________________

16. Reported age of first prenatal care visit patients by percent:

For the following groups, indicate the reported age of first prenatal care visit patients at this medical practice location/office. Please provide an estimate if the exact percent is not known. The total percentage for all ages cannot be greater than 100%.

Patients under 20 years old: %

Patients between 20 – 24 years old: %

Patients between 25 – 29 years old: %

Patients 30 or more years old: %

17. Is this location part of a larger practice with multiple locations?

___ Yes ___ No → End of Questionnaire.

18. Name of the larger practice referenced in Question 17: _______________________________

19. Name and contact information for Administrative contact (Medical Director, CEO, etc.) for this larger practice:

 Same as Question 5 → Go to Question 20.

Name: _______________________________________________________________________

Position/Role: _______________________________________________________________________

Street Address: _______________________________________________________________________

Suite/Unit#: _______________________________________________________________________

City: ________________________________________________________________________

State: ________________________________________________________________________

Zip Code: ________________________________________________________________________

Email Address: ________________________________________________________________________

Phone Number: ()  -  Ext: 

Preferred mode of contact: ______________________________________________

20. Number of locations in the practice where prenatal services are provided:

 Total Locations

21. Number of births per year for all providers/clinicians in the practice listed in Question #18:

 Total Births

22. Number of births per year for all providers in the practice from women who reside in Jefferson County. (This is a subset of Question #21).

 Total Births In Jefferson County

Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 27892-7974, ATTN: PRA (0925-0593*). Do not return the completed form to this address.