Form 1 NCORP Program Site Level Attributes Survey

NCI Community Oncology Research Program

Practice Survey of Site-Level Attributes

OMB No.: 0925-0046

Expiration Date: 11/30/2022

Public reporting burden for this collection of information is estimated to average 10 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 20892-7974, ATTN: PRA (0925-0046). Do not return the completed form to this address.

This form will collect various NCORP Site-level attributes for each practice (affiliate/sub-affiliate) that will participate in a cancer care delivery research (CCDR) trial. Results will be used to inform study design considerations, increase practice recruitment and generalizability of clinical trials, and enhance an understanding of challenges/barriers to practice participation in CCDR studies.

Please complete all questions on the following data collection form and upload to the CTSU Regulatory Office using the Regulatory Submission Portal located in the Regulatory section of the CTSU website. We greatly appreciate your participation.

NCORP Affiliate/Sub-affiliate: _________________________________________ CTEP ID Code: _____________

1. Practice Setting (Please select one item).

• Independently owned (i.e. single hospital or small regional network (up to three hospitals) or an independent clinic/physician practice)

• Hospital, clinic, or physician practice owned by a large regional/multi-state health system that does include a health plan

• Hospital, clinic, or physician practice owned by a large regional/multi-state health system that does not include a health plan

• HMO/Payer owned

• Publicly owned (e.g. state, county, city)

• Academic medical center (e.g., university-based hospital)

2. Profit status (Please select one item).

• Private for Profit

• Private Not for Profit

• Government

3. Safety Net Designation

3a. Has your organization been formally designated as a Federally Qualified Health Center (FQHC)? (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/fqhcfactsheet.pdf)

• Yes

• No

3b. Has your organization been formally designated a Critical Access Hospital? (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/CritAccessHospfctsht.pdf)

• Yes

• No

3c. Has your organization been formally designated a Rural Health Clinic? (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/RuralHlthClinfctsht.pdf)

• Yes

• No

4. New Analytic Cancer Cases

4a. Estimated total number of new analytic cancer cases/year at your affiliate/sub affiliate (for most recent year available): _______________

4b. Estimated proportion of new analytic cancer cases at your affiliate/sub affiliate that are members of the following racial groups (Numbers should total 100%):

____% White

____% Black/African American

____% Asian

____% Native Hawaiian/Other Pacific Islander

____% American Indian/Alaskan Native

4c. Estimated proportion of new analytic cancer cases at your affiliate/sub affiliate that are members of the following ethnic groups (Numbers should total 100%):

____% Hispanic

____% Non-Hispanic