OMB Number: 0915-0366; Expiration date: XX/XX/202X
Entities Survey: Module 6
Number of questions: 16
This module is relevant for the following entity identified in Module 2:
State Licensing Board, State Certification Authority and Federal Licensing Agency
Demographics Related Questions
Q 6.1. For the typical year, how many applications (new and renewals) for licensure or certification does your organization receive?
Select a number: __________
Do not know (Please Explain) ________
Q 6.2. For the typical year, how many applications (new and renewals) does your organization approve for licensure or certification?
Select a number: __________
Do not know (Please Explain) ________
Q 6.3. How many total staff members within your organization are responsible for licensing or certifying practitioners?
Select a number: __________
Do not know (Please Explain) ________
Q 6.4. How often does your organization review the records of practitioners for which your organization has granted licensure or certification?
Once every 6 months
Once per year
Once every 2 years
Once every 3 years
Once every 4 or more years
Ongoing
Other (Please Explain) _________
Q 6.5. Which of the following sources does your organization utilize for granting licensure or certification to a practitioner? (Please select all that apply.)
National Practitioner Data Bank (NPDB)
Practitioner’s Self-Queries of the NPDB
Board Action Data Bank of the Federation of State Medical Boards (FSMB) or other national organization(s) of state licensing boards for non-physician practitioners
Licensing board(s) in your state
Licensing board(s) in another state
Practitioner’s current medical malpractice/liability insurance carrier(s)
Practitioner’s previous medical malpractice/liability insurance carrier(s)
Practitioner’s current affiliated health plan(s)
Practitioner’s previous affiliated health plan(s)
Other health care entities (other hospitals, HMOs, group practice, etc.)
Professional society(ies) (e.g., AMA, AOA, ANA, etc.).
Medical school(s) or other professional school(s)
Residency program(s)
Speciality certification organizations (e.g., ABMS)
OIG exclusion list
Drug Enforcement Agency exclusion list
Peer or professional references
Other (Please Explain) ____________
Survey Page Break
Q 6.6. What types of adverse licensure or certification actions does your organization take regarding practitioners? (Select all that apply.)
Revocation of License or Certification
Probation of License or Certification
Suspension of License or Certification
Summary or Emergency Limitation or Restriction on License or Certification
Summary or Emergency Suspension of License or Certification
Reprimand or Censure
Voluntary Surrender of License
Voluntary Limitation or Restriction on License
Limitation or Restriction on License or Certification
Denial of License or Certification Renewal
Denial of Initial License or Certification
Interim Action – Voluntary Agreement to Refrain from Practice or to Suspend License or Certification Pending Completion of an Investigation
Cease and Desist
Withdrawal of Renewal Application While Under Investigation
Publicly Available Fine/Monetary Penalty
Prescriptive/Dispensing Authority Action – Not Classified (Please Specify) _____
Publicly Available Negative Action or Finding (Please Specify) ________
Other Licensure or Certification Action – Not Classified (Please Specify) _____________
Q 6.7. For the typical year, how many times does your organization take disciplinary actions regarding practitioners?
None
1 to 5 times
5 to 24 times
25 to 49 times
50 to 99 times
100 or more times
Do not know (Please Explain)
Q 6.8. Has your organization ever been found to be non-compliant with the NPDB reporting requirements?
Yes
No skip the next question
Do not know skip the next question
Q 6.9. Please rate your organization’s level of satisfaction with the NPDB’s efforts to promote your organizations’ compliance?
Very Satisfied
Satisfied
Neither Satisfied Nor Dissatisfied
Dissatisfied
Very Dissatisfied
Survey Page Break
Q 6.10. Is your organization a state medical board?
Yes
No
Q 6.11. Does your organization receive clinical privileges action reports from the NPDB’s report forwarding service?
Yes
No
Not Applicable
Other (Please Explain) ________
If “yes,” go to the next question. Otherwise, skip to Q 6.13.
Q 6.12. How would you rate your level of satisfaction with the NPDB’s report forwarding service for clinical privileges actions?
Very Satisfied
Satisfied
Neither Satisfied Nor Dissatisfied
Dissatisfied
Very Dissatisfied
Q 6.13. Does your state medical board receive medical malpractice payment reports from the NPDB’s reporting forwarding service?
Yes
No
Not Applicable
Other (Please Explain) ________
If “yes,” go to the next question. Otherwise, end this module.
Q 6.14. How would you rate your level of satisfaction with the NPDB’s report forwarding service for medical malpractice payment reports?
Very Satisfied
Satisfied
Neither Satisfied Nor Dissatisfied
Dissatisfied
Very Dissatisfied
Survey Page Break
Q 6.15. Does your state medical board have a monetary penalty for hospitals for not reporting clinical privileges actions to the state medical board?
Yes
No Skip to the end of the module.
Not Applicable (Please Explain) ______________ Skip to the end of the module.
Q 6.16. Please provide the details of the monetary penalty.
Textbox
Piping Logic:
Survey will be directed to Module 8 next.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Microsoft User |
| File Modified | 0000-00-00 |
| File Created | 2021-02-15 |