OMB Number: 0915-0366; Expiration date: XX/XX/202X
Entities Survey: Module 2
Number of questions: 2
Demographic Information
We are collecting demographic information so that we can describe the different kinds of NPDB entities participating in this survey.
Q 2.1. In what region of the country is your organization located? If your organization operates in multiple regions, select all that apply by rank ordering them.
Region 1: Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, or Vermont
Region 2: New Jersey, New York, Puerto Rico, or Virgin Islands
Region 3: Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, or West Virginia
Region 4: Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, or Tennessee
Region 5: Illinois, Indiana, Michigan, Minnesota, Ohio, or Wisconsin
Region 6: Arkansas, Louisiana, New Mexico, Oklahoma, or Texas
Region 7: Iowa, Kansas, Missouri, or Nebraska
Region 8: Colorado, Montana, North Dakota, South Dakota, Utah, or Wyoming
Region 9: Arizona, California, Hawaii, Nevada, American Samoa, Northern Mariana Islands, Federated States of Micronesia, Guam, Marshall Islands, or Republic of Palau
Region 10: Alaska, Idaho, Oregon, or Washington
Q 2.2. Which of the following best characterizes your organization?
My organization reports adverse actions or malpractice payments to the NPDB that occur in my organization’s region (e.g., an independent hospital located in one area or a hospital system reporting from a single area).
My organization reports adverse actions or malpractice payments to the NPDB that occur in multiple regions (e.g., a hospital system located in multiple regions and reporting from the respective regions).
Survey Page Break
Q 2.3. Which of the following best describes your organization? Select one category.
Hospital or Hospital System
Health Plan
Other Health Care Entities (e.g., Group Practice, Community Health Center, Clinic, Urgent Care or Ambulatory Health Care Facility or another health care organization that is not a hospital)
Professional Society
Medical Malpractice Payer
State Licensing Board or State Certification Authority
Federal Licensing Agency
Federal or State Prosecutor (including Attorney General)
Other State Agency
Other Federal Agency
Authorized Agent for NPDB Registered Health Care Entities
Other (Please Explain)__________
Depending on the participant’s response above, survey will be directed to the next module as described below (see further details in the survey flowchart):
Hospital or Hospital System Module 3
Health Plan Module 4
Other Health Care Entities Module 4
Professional Society Module 5
State Licensing Board Module 6
State Certification Authority Module 6
Federal Licensing Agency Module 6
Federal or State Prosecutor (including Attorney General) Module 7
Other State Agency Module 8
Other Federal Agency Module 8
Other (Please Explain) Module 8
Authorized Agent for NPDB Registered Health Care Entities Module 24
Medical Malpractice Payer Module 31
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Microsoft User |
| File Modified | 0000-00-00 |
| File Created | 2021-04-12 |