Form 3 Pre-Site Site Interview Form

Provider Pre-Site Visit Interview

Date of interview call	RS Name
Facility Name	Location (City, State)
Participants (full name & credentials)	Title and Role

Logistics and approvals

1. According to our records, our site visit is schedule for [say dates]. Do these dates that still work for your site?

   1. Yes

   2. No

1.1 IF NO, what weeks between [month and month] would work for you?

2. According to your screening interview your facility requires [IRB approval, memorandum of understanding (MOU), business associate agreement (BAA) and/or confidentiality agreement]. What do you need from us to facilitate the approval process?

3. IF MOU, BAA or confidentiality agreement: can you please send us a draft by [date] so that our contracts department can review?

EHR

4. Other than the above approvals, is there anything else above that you need from us to gain access to the EHR your facility uses?

Paper-based

5. Other than the above approvals, is there anything else above that you need from us to gain access to the paper-based records your facility uses?

Now we are going to move to the interview portion of the call, and we are going to start by verifying your facility characteristics

Facility Demographics

1. What is the official name of your facility? Sometimes names vary a bit, so we want to confirm:

2. What are your current Ryan White funding sources?

   1. Part A

   2. Part B

   3. Part C

   4. Part D

   5. Part F

3. What model of care do you provide?

   1. Exclusively primary care

   2. Primary care-dominant, co-management:

   3. Specialist-dominant, co-management:

   4. Exclusively HIV specialist care

4. How many and what types of healthcare providers are employed by your clinic to provide HIV care?

Type	Number full-time	Number part-time
MD or DO
PA
NP
RN
MA
Pharmacist
Social Worker
Behavioral Health Counselor

5. Is your clinic fully staffed?

6. Does your clinic empanel patients by physician?

7. Please complete the demographic information for each physician, nurse practitioner, and physician assistant on staff.

Name	Board Certification(s)	Age Band*	Race/Ethnicity	Gender

*Band values: 1. Under 25 years old, 2. 25 – 34 years old, 3. 35 – 44 years old, 4. 45 – 54 years old, 5. 55 or over, 6. Don’t know or refused to answer

8. What is the total number of active patients in your clinic?

Screening documentation

In your EHR or paper records:

9. Where do you document vaccinations?

10. Where do you document all your screenings?

    1. TB screening?

    2. STI screening?

    3. Pap smears?

11. How do you document syphilis treatment? (E.g. medication list, prescribed medications, physician notes?)

Mental Health Services

12. How frequently are mental health screenings performed?

13. What are your mental health screening policies? (E.g. do you screen a patient who is in treatment?)

14. What type of mental health screening tests are performed?

    1. PHQ-2 (Patient Health Questionnaire-2)

    2. PHQ-9 (Patient Health Questionnaire-2)

    3. SAMISS (Substance Abuse and Mental Illness Symptom Screener)

    4. CES-D (Center for Epidemiologic Studies Depression Scale)

    5. GAD-7 (Generalized Anxiety Disorder 7-item)

    6. Abbreviated PCL-C (PTSD Civilian Check-list)

    7. Kessler Psychological Distress Scale - 6

    8. Kessler Psychological Distress Scale -10

    9. Beck Anxiety Inventory (BAI)

    10. Beck Depression Inventory (BDI)

    11. BDI – Fast Screen for Medical Patients

    12. Beck Scale for Suicide Ideation (BSS)

    13. Beck Hopelessness Scale (BHS)

    14. Clark-Beck Obsessive-Compulsive Inventory (CBOCI)

    15. Other

15. Where in your EHR or paper files are screening for alcohol and substance use disorders documented? (Probes: What tab or section? In the provider notes? Some other place?)

Substance Use/Opioid Dependence

16. How frequently do you screen for substance use disorder?

17. What type of substance use screening tests are performed?

    1. National Institute on Drug Abuse (NIDA) Quick Screen V1.0

    2. NIDA Modified ASSIST V2.0

    3. Drug Abuse Screening Test (DAST-10)

    4. Michigan Alcoholism Screening Test (MAST)

    5. Triage Assessment for Addictive Disorders (TAAD)

    6. CAGE Substance Abuse Screening Tool

    7. UNCOPE Screening Tool

    8. CRAFFT Screening Tool

    9. Other

18. Where in your EHR or paper files are screening for alcohol and substance use disorders documented? (Probes: What tab or section? In the provider notes? Some other place?)

19. If substance use is identified, how do you refer patients to services?

20. What substance use services are internal and what are external? Where is this documented in the patient record?

21. How do you document Medication Assistance Therapy? (e.g. physician note if prescribed outside the clinic, Prescribed medication list)

22. Does your facility record the results of referrals? If so, how and where?

23. Do you have syringe services in your community? If yes, do you refer to these services?

24. Do you have safe injection sites in your community? If yes, do you refer to these services?

Cervical Pap Smear

25. How are the results of a cervical Pap smear documented in the chart? (Probes: What tab or section? In the provider notes? Some other place?)

26. How are the results of colposcopy documented in the chart? (Probes: What tab or section? In the provider notes? Some other place?)

Public reporting burden for his collection of information is estimated to average 1 hours per response, including the time for reviewing instructions, searching existing data sources, 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 this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857.

OMB No. 0906 – xxxx Expiration Date XX/XX/20XX