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Appendix A – Individual Respondent Characteristics

Form Approved
OMB No. xxxx-xxxx
Exp. Date xx/xx/20

Diagnostic Safety Capacity Building – Calibration Resource

Please complete the following information about yourself. This document is completed at the time of recruitment/interview and will take approximately 15 minutes to complete. Participation in the survey is voluntary.

Individual Respondent Characteristics Survey

Characteristic	Response Option*
Sex	Male Female
Race	Check all that apply: White Black or African American American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander
Ethnicity	Hispanic or Latino Not Hispanic or Latino
Age in years
Professional Background	Physician (MD/DO) Physician Assistant Nurse Practitioner
Specialty and/or board certification(s)
Number of years in practice (since licensure)
Location	City, State: ___________________________
Practice Setting(s)	Office-based practice Primary Care Specialty Care FQHC Multispecialty Urgent Care Center Emergency Room Hospital Other: ____________________________
Organization type	 Academic medical center  Other not-for-profit  For-profit
Do you hold an academic appointment or affiliation?	Yes No
Are you involved in training learners in your discipline (e.g., medical students, interns, residents, and/or fellows)?	Yes No
*Each characteristic must include an option for did not respond/did not provide an answer

This survey is authorized under 42 U.S.C. 299a. The confidentiality of your responses to this survey is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)].  Information that could identify you will not be disclosed unless you have consented to that disclosure. Public reporting burden for this collection of information is estimated to average 15 minutes per response, the estimated time required to complete the survey. 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: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 5600 Fishers Lane, Room #07W42, Rockville, MD 20857.

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