Form 0920-0234 2025-2027 Health Center Component Facility Interview

Attachment C2

2025-2027 Health Center Component Facility Interview

Form Approved

OMB No. 0920-0234

Exp. date XX/XX/20XX

NOTICE - Public reporting burden of this collection of information is estimated to average 45 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: CDC/ATSDR Information Collection Review Office; 1600 Clifton Road, MS H21-8, Atlanta, GA 30333, ATTN: PRA (0920-0234).

Assurance of Confidentiality: We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 U.S.C. 242m(d)) and the Confidential Information Protection and Statistical Efficiency Act or CIPSEA (44 U.S.C. 3561-3583).  In accordance with CIPSEA, every NCHS employee, contractor, and agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you.  In addition to the above cited laws, NCHS complies with the Federal Cybersecurity Enhancement Act of 2015 (6 U.S.C. §§ 151 and 151 note) which protects Federal information systems from cybersecurity risks by screening their networks.

Script: Hello, my name is _____________, calling on behalf of the CDC’s National Center for Health Statistics regarding their study of health centers, as part of the National Ambulatory Medical Care Survey, or NAMCS. May I ask whom I am speaking with?

We are in the process of confirming and updating our contact information. Can I ask you a few questions about your center?

Name: [INTROCALL_NAME] [C]

Title: [INTROCALL_TITLE] [C]

Contact number: [INTROCALL_PHONE] [C]

Extension: [INTROCALL_EXT] [C]

Call notes: [INTROCALL_NOTES] [C]

_{Initial Confirmation and Telephone Screen Call}

1. Will you please tell me if the following information is correct?

Health center name: [HC_NAME_CHK] [N]

Authorized Official Name and Salutation: (Mr./Ms./Miss/Mrs./Dr.) [HC_DIR_SALUTE] [C]

[HC_DIR_NAME_CHK] [N]

Authorized Official Title: [HC_DIR_TITLE] [C]

Email Address: [HC_DIR_EMAIL_CHK] [N]

Address: [HC_ADDRESS_CHK] [N]

City: [HC_CITY_CHK] [N]

State: [HC_STATE_CHK] [N]

ZIP code: [HC_ZIP_CHK] [N]

Telephone number: [HC_DIR_PHONE_CHK] [N] Extension: [HC_DIR_PHONE_EXT_CHK] [N]

CONTINUE WITH Q2

2. Which of the following best describes your center? [HCTYPE] [N]

• Federally Qualified Health Center (330 grantee) à CONTINUE WITH Q3

• Federally Qualified Health Center Look-Alike à SKIP TO Q5

• Urban Indian (437) Health Center à READ SCRIPT BELOW AND CONCLUDE INTERVIEW

• Other (Please Specify) à SKIP TO Q4

If informant selects “URBAN INDIAN HEALTH CENTER” READ the script below and conclude the interview.

Script: At this time, we are only interviewing Federally Qualified Health Centers (FQHCs) and FQHC Look-Alikes. Thank you for your time.

3. Can your center also be classified as a: [FQHCTYPE] [N]

Note: Select all that apply.

• Migrant Health Center (MHC)

• Health Care for the Homeless (HCH)

• Public Housing Primary Care (PHPC) Grant Program

• None of the above

• Blank à SKIP TO Q5

SKIP TO Q5

4. Other – please Specify: ______________ [HCTYPEOTH] [C]

• Blank à READ SCRIPT BELOW AND CONCLUDE INTERVIEW

READ SCRIPT BELOW AND CONCLUDE INTERVIEW

Script: At this time, we are only interviewing Federally Qualified Health Centers (FQHCs) and FQHC Look-Alikes, I need to confirm your health center’s eligibility and get back to you. Thank you for your time.

5. Are you the official who can agree to participate in NAMCS on behalf of the (INSERT HEALTH CENTER NAME)? [CONF_HCOFFIC] [N]

• Yes à Skip to Q12 and read introduction script

• No à Continue with Q6

6. Will you please identify an official who can agree to participate in NAMCS on behalf of the [INSERT HEALTH CENTER NAME]?

Note: This official could be the CEO, Director of Quality Control/Assurance, Health Information Management (HIM) Director, Research Director or someone else.

Salutation/Name: (Mr./Ms./Miss/Mrs./Dr.) [AUTH_SALUTE] [C]

[AUTH_FIRST] [C] [AUTH_LAST] [C]

Title: [AUTH_TITLE] [C]

Telephone number: [AUTH_PHONE] [C] Extension: [AUTH_PHONE_EXT] [C]

Email Address: [AUTH_EMAIL] [C]

Address: [AUTH_ADDRESS] [C]

City: [AUTH_CITY] [C]

State: [AUTH_STATE] [C]

ZIP Code: [AUTH_ZIP] [C]

Continue with Q7

7. Can you please confirm if [INSERT TITLE FROM Q1 or Q6 or Q11] received an information packet and invitation to participate in NAMCS? [CEN_INFOPAK] [N]

• Yes

• No

Continue with Q8

8. Can you please transfer me to [INSERT NAME FROM Q1 or Q6 or Q11]? [TRANSFER] [N]

• Yes à SKIP TO Q10

• No à CONTINUE WITH Q9

9. When would be a good time to call back and speak with the [INSERT TITLE FROM Q1 or Q6 or Q11]?

_____/______/_____ [CALLBACK1_DATE] [C]

Day / Month/Year

Time: _____:_____ _____A.M. _____P.M. _____Time Zone [CALLBACK1_TIME] [C]

Call Note: [CALLNOTE1] [C]

• Blank

Script: We will reach back out on [repeat date and time of scheduled call back]. Thank you for your time.

CONTINUE WITH Q10 DURING CALL BACK.

TRANSFER TO OFFICIAL:

Script: Hello, my name is _____________, calling on behalf of the Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS) regarding the National Ambulatory Medical Care Survey, known as NAMCS. The NCHS selected (INSERT HEALTH CENTER NAME) as part of a nationally representative sample to participate in NAMCS. You were identified as someone who could authorize participation in NAMCS. If I could have a few minutes of your time, I’d like to ask you a few questions about your health center.

IF HEALTH CENTER OFFICIAL INFORMS THE INTERVIEWER THAT THIS IS NOT A GOOD TIME, RETURN TO QUESTION 9 TO LOG CALL BACK DATE/TIME.

10. As the [INSERT TITLE FROM Q1 or Q6 or Q11], are you authorized to agree to participate on behalf of [INSERT HEALTH CENTER NAME]? [AUTH_RESPONDENT] [N]

• Yes à Skip to Q12 AND READ PRIOR INTRODUCTION SCRIPT

• No à Continue with Q11

11. Who is the best person who can authorize participation in the survey?

Name: (Mr./Ms./Miss/Mrs./Dr.) [AUTH_SALUTE2] [C] [AUTH_FIRST2] [C] [AUTH_LAST2] [C]

Job title: [AUTH_TITLE2] [C]

Telephone Number: [AUTH_PHONE2] [C] Extension: [AUTH_EXT2] [C]

E-mail: [AUTH_EMAIL2] [C]

Address: [auth_address2] [c]

City: [AUTH_CITY2] [C]

State: [AUTH_STATE2] [C]

zip code: [AUTH_ZIP2] [C]

Go back to Q7

INTRODUCTION (For A New authorizing official confirmed in q6 or Q11)

Script (read during current call): The NCHS selected (INSERT HEALTH CENTER NAME) as part of a nationally representative sample to participate in NAMCS. Your participation in the survey is voluntary and will help health care providers and professionals plan for more effective health services, improve medical and health education, and assist the public health community in understanding the patterns of diseases and health conditions. If you choose to participate in NAMCS, the NCHS will offer your health center a set-up fee of up to $10,000 to help transmit patient level electronic health record (EHR) data such as medical records and visits for the calendar year.

Script (read during call back): Hello, my name is BLANK, and I am calling on behalf of the Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS) regarding the National Ambulatory Medical Care Survey, known as NAMCS. We spoke the other day and you mentioned this was a good time to call back and ask you a few questions about your health center. Is this still a good time?

_{Interview with Health Center} Official

12. Did you receive the NAMCS information packet? [AUTH_INFOPAK] [N]

• Yes, no need to send it again à Skip to Q17

• Yes, but can you please send it again à CONTINUE WITH Q13

• No à Script: I apologize and will ensure the information is sent to you right away. à Continue with Q13

13. Would you prefer to receive it via email or in the mail? [AUTH_INFO_LETTER] [N]

• Email à CONTINUE WITH Q14 TO CAPTURE AND SEND EMAIL

• Mail à SKIP TO Q15 TO CONFIRM MAILING ADDRESS TO BE USED TO SEND A NEW LETTER

• Blank à CONTINUE WITH Q14

14. What email address would you like us to send it to? _________________________ [AUTH_INFO_EMAIL] [C]

• Blank à CONTINUE WITH Q15

SKIP TO Q16

15. Could you please confirm the following contact information? [AUTH_CONFIRM] [N]

CONFIRM AUTHORIZED OFFICIAL CONTACT AND MAILING INFORMATION TO MAIL NEW RECRUITMENT PACKAGE.

PROGRAMMING NOTE: FILL WITH DATA FROM Q1 OR Q6 OR Q11

Name: (Mr./Ms./Miss/Mrs./Dr.)

Health Center name:

Address:

City, State and ZIP code:

E-mail:

• Valid

• Invalid

CONTINUE WITH Q16

Script: I’d like to give you some time to review the information I provided regarding NAMCS.

16. When would be a good time to call back?

_____/______/_____ [CALLBACK2_DATE] [C]

Day / Month /Year

Time: _____:_____ _____A.M. _____P.M. _____Time Zone [CALLBACK2_TIME] [C]

Call Note: [CALLNOTE2] [C]

• Blank

Script: We will reach back out on [repeat date and time of scheduled call back]. Thank you for your time.

DURING CALL BACK, READ SCRIPT BELOW AND CONTINUE WITH Q17

Script (read during call back): Hello, my name is BLANK, and I am calling on behalf of the Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS) regarding the National Ambulatory Medical Care Survey, known as NAMCS. We spoke the other day and you mentioned this was a good time to call back and ask you a few questions about your health center. Is this still a good time?

17. Do you have any questions about the information you received or concerns about what we have discussed so far? [AUTH_QUES] [N]

• Yes à Continue with Q18

• No à Skip to Q19

• Blank à SKIP TO Q19

18. Record major topics below. Use materials to try to address each one.

___________________________________ [AUTHTOPIC_1] [C]

___________________________________ [AUTHTOPIC_2] [C]

___________________________________ [AUTHTOPIC_3] [C]

___________________________________ [AUTHTOPIC_4] [C]

___________________________________ [AUTHTOPIC_5] [C]

• Blank

CONTINUE WITH Q19

19. Can we count on your health center’s participation in NAMCS? [HCPART] [N]

• Yes à Continue with q20

• Need more time to decide à CONTINUE WITH Q22

• No, health center official declines to participate. à skip to q23

CONTINUE WITH Q20

20. What is your health center’s EHR vendor, product and version number?

Note: Please reach out to your health center’s IT team or someone who is very familiar with your health center’s EHR system to obtain this information. If you need further assistance, please reach out to the NAMCS Health Center Support Team by telephone at 1-800-307-0134 (toll-free) or 301-458-4050 (local) or email NAMCSHealthCenters@cdc.gov.

EHR Vendor: [ehr_vendor] [C]

ehr Product: [ehr_PRODUCT] [C]

eHR Version Number: [ehr_veRSION] [C]

CONTINUE WITH Q21

21. Will you please identify the primary IT/data contact, the individual responsible for transmitting your health center’s data and what is their contact information?

Name: (Mr./Ms./Miss/Mrs./Dr.) [IT _SALUTE] [C] [IT _FIRST] [C] [IT _LAST] [C]

Job title: [IT _TITLE] [C]

Telephone Number: [IT _PHONE] [C] Extension: [IT _EXT] [C]

E-mail: [IT _EMAIL] [C]

Script: That concludes the telephone portion of the Facility Interview Questionnaire. The remainder of the interview will be available through an online application. We will email you shortly with a unique link and login information to access the application. If you have any questions, please don’t hesitate to reach out to the NAMCS Health Center Support Team by telephone at 1-800-307-0134 (toll-free) or 301-458-4050 (local) or email NAMCSHealthCenters@cdc.gov. Thank you so much for your time and we are very excited to work with you and your health center.

22. When would be a good time to call back?

_____/______/_____ [CALLBACK3_DATE] [C]

Day / Month/Year

Time: _____:_____ _____A.M. _____P.M. _____Time Zone [CALLBACK3_TIME] [C]

Call Note: [CALLNOTE3] [C]

• Blank

Script: We will reach back out on [repeat date and time of scheduled call back]. Thank you for your time.

CONCLUDE INTERVIEW. DURING CALL BACK, GO BACK TO Q19

23. Please tell me why your health center does not want to participate.

RECORD RESPONSE TO BE CODED LATER: ___________________ [REFUSE_REPONSE] C]

• Blank

THANK THE OFFICIAL FOR THEIR TIME AND END INTERVIEW. CONTINUE WITH Q24 AFTER THE CALL.

24. DO NOT READ THESE RESPONSES OUT LOUD; Instead; check the option that best captures the official’s reason for refusal. [WHY_REF] [N]

• Confidentiality concerns à CONCLUDE INTERVIEW

• The health center’s financial situation does not permit it to dedicate time to this effort à CONCLUDE INTERVIEW

• The health center has too many other priorities at this time à CONCLUDE INTERVIEW

• Limited staffing resourcesà CONCLUDE INTERVIEW

• Other à CONTINUE WITH Q25

• Blank à CONCLUDE INTERVIEW

25. Other – please specify: ____________________________________ [REFUSE_OTH] [C]

• Blank

_{Health Center Primary Contact Interview}

Message displayed on the first screen of the online Facility Interview: Thank you for agreeing to participate in the National Ambulatory Medical Care Survey (NAMCS), the Nation’s foremost study of the provision and use of ambulatory medical care services. NAMCS is conducted by the National Center for Health Statistics (NCHS), part of the Centers for Disease Control and Prevention (CDC). Success of the survey depends on the willingness of health centers like yours to provide important data.

The following questions are part of the NAMCS Facility Interview. If you have questions at any time during this questionnaire, please reach out to the NAMCS Health Center Support Team by telephone at 1-800-307-0134 (toll-free) or 301-458-4050 (local) or email NAMCSHealthCenters@cdc.gov.

26. Is this health center a subsidiary of a larger company or network? [HC_NETWORK] [N]

• Yes à CONTINUE WITH Q27

• No à SKIP TO Q28

• Don’t know à SKIP TO Q28

27. What is the name of the larger company or network? [NETWORK_NAME] [C]

• Blank

Continue with Q28

28. Are other health centers covered under your state license? [HC_LICENSE] [N]

Note: Health center care delivery sites under the sampled health center with the same name or a different name are considered as part of the sampled health center and not considered as an “other health center.”

• Yes à CONTINUE WITH Q29

• No à SKIP TO Q30

• Don’t know à SKIP TO Q30

• Blank à SKIP TO Q30

29. What are the name(s) of the health center(s)?

Note: Health center care delivery sites under the sampled health center with the same name or a different name are not considered as “other health centers.”

[HC_LICENSENAM1] [C] _________________________________

[HC_LICENSENAM2] [C] _________________________________

[HC_LICENSENAM3] [C] _________________________________

• Blank

Continue with Q30

30. When this health center reports data to the governing bodies is the information solely for this health center or are other health centers included in the data transmission? [REPDATOTH] [N]

Note: Health center care delivery sites under the sampled health center with the same name or a different name are not considered as “other health centers.”

• Solely for this health center à Skip to Q32

• Combined with one or more other health centers à Continue with Q31

• Blank à SKIP TO Q32

31. What are the name(s) of the other health centers?

Note: Health center care delivery sites under the sampled health center with the same name or a different name are not considered as “other health centers.”

___________________________________________ [REPDATOTH_NAM1] [C]

___________________________________________ [REPDATOTH_NAM2] [C]

___________________________________________ [REPDATOTH_NAM3] [C]

• Blank

Continue with Q32

Part 2. General Questions

32. Was this health center open for the full calendar year (FILL PREVIOUS CALENDAR YEAR)? [HCOPEN_PREV] [N]

• Yes à SKIP TO Q34

• No à CONTINUE WITH Q33

• Never open in (FILL PREVIOUS CALENDAR YEAR)à SKIP TO Q34

33. Please provide the dates the health center was closed in (FILL PREVIOUS CALENDAR YEAR): ______________________________________________

Period 1: [startmth1] [startday1] [endmth1] [ENDDAY1] [n] ☐ Exact ☐ Estimate

Period 2: [STARTMTH2] [STARTDAY2] [ENDMTH2] [ENDDAY2] [n] ☐ Exact ☐ Estimate

Period 3: [startmth3] [startday3] [endmth3] [ENDDAY3] [n] ☐ Exact ☐ Estimate

CONTINUE WITH Q34

34. Do you anticipate any significant changes in your visit volume in (FILL CURRENT CALENDAR YEAR)? [VISCHG_CURR] [N]

• Yes à Continue with Q35

• No à SKIP TO Q36

35. Please explain: _______________ [WHY_VISCHG_CURR] [C]

• Blank

Continue with Q36

36. During its last normal year, approximately how many office visit encounters did this health center have?

Note: An example of a normal year is 2019, prior to COVID-19. Only include in-person and telemedicine or telehealth visits to the sampled health center, including health center care delivery sites with the same or a different name.

• Enter number of visits: ______________________________________ [AVG_TOTVIS] [N]

continue with Q37

37. Approximately how many office visit encounters do you estimate this health center will have in (FILL CURRENT CALENDAR YEAR)?

Note: Only include in-person and telemedicine or telehealth visits to the sampled health center, including health center care delivery sites with the same or a different name.

• Enter estimated visits: ____________________________________ [EST_TOTVIS_CURR] [N]

continue with Q38

38. Please provide the actual counts or your best estimates for the total number of health center visits during calendar year (FILL PREVIOUS CALENDAR YEAR) for each quarter if possible, and for the year overall.

Note: Only include in-person and telemedicine or telehealth visits to the sampled health center, including health center care delivery sites with the same or a different name.

	Quarter 1	Quarter 2	Quarter 3	Quarter 4	Annual
All visits made to health center:	[TOTVISQ1] [C] Blank	[TOTVISQ2] [C] Blank	[TOTVISQ3] [C] Blank	[TOTVISQ4] [C] Blank	[TOTVIS] [C]

Continue with Q39

_{Electronic Health Records (EHR)}

39. Are you able to electronically output patient level data from your electronic health record (EHR) system? [EHR_OUPUT] [N]

• Yes

• No

• Don’t know

Continue with Q40

40. Does your health center already have an established Health Information Service Provider (HISP) that can be used to transfer secure Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliant data?

Note: Please reach out to your health center’s IT team or someone who is very familiar with your health center’s EHR system to obtain this information. If you need further assistance, please reach out to the NAMCS Health Center Support Team by telephone at 1-800-307-0134 (toll-free) or 301-458-4050 (local) or email NAMCSHealthCenters@cdc.gov.

• Yes

• No

• Don’t know

CONTINUE WITH Q41

41. Do you need assistance setting up your EHR system to ensure that it is compatible with the Health Level 7 (HL7) Clinical Document Architecture (CDA®) R2 Implementation Guide (IG): National Health Care Surveys (NHCS) Release 1, Draft Standard for Trial Use (DSTU) 1.2 – U.S. Realm (NHCS IG 1.2)? [EHR_SETUP] [N]

• Yes

• No

• Don’t know

Text prompt if “Yes” or “Don’t know” are selected: A member of the NAMCS Health Center Support Team will be in touch shortly to help ensure that your EHR system is compatible with the NHCS IG 1.2.

CONTINUE WITH Q42

42. Will the data you provide include electronic health records from your health center only?

[EHR_HCONLY] [N]

Note: Health center care delivery sites under the sampled health center with the same name or a different name are considered one health center.

• Yes à SKIP TO Q46

• No à CONTINUE WITH Q43

• Don’t know à SKIP TO Q46

43. Is it possible to identify the records from your health center separate from the other health centers that report with you? [EHR_HCID] [N]

Note: Health center care delivery sites under the sampled health center with the same name or a different name are considered one health center.

• Yes

• No

• Don’t know

CONTINUE WITH Q44

Data Transfer

44. What are the name(s) of the other health centers included?

Note: Health center care delivery sites under the sampled health center with the same name or a different name are considered one health center.

_______________________________________________________

[EHR_OTHNAM1] [C]

[EHR_OTHNAM2] [C]

[EHR_OTHNAM3] [C]

Continue with Q45

45. How can we make that distinction? ________________ [EHR_DIST] [C]

Continue with Q46

_{Electronic Health Records (EHR) and Telemedicine}

46. Does your health center use an EHR to…?	Yes	No	Don’t Know	Not Applicable	Blank
Record social determinants of health (e.g., employment, education, race/ethnicity, language and literacy skills)?
Record behavioral determinants of health (e.g., tobacco use, physical activity, alcohol use, drug use, diet)?
Order prescriptions?
Send prescriptions electronically to the pharmacy?

Continue with Q47

47. At your health center, what type(s) of telemedicine do you use for patient visits?

Note: Check all that apply.

• Videoconference software with audio (e.g., Zoom, WebEx, FaceTime) à SKIP TO Q49

• Audio without video conference software à SKIP TO Q49

• Telemedicine platform NOT integrated with EHR (e.g., Doxy.me) à SKIP TO Q49

• Telemedicine platform integrated with EHR (e.g., update clinical documentation during telemedicine visit) à SKIP TO Q49

• Other tool(s) à CONTINUE WITH Q48

• The health center does not use telemedicine for patient visits à SKIP TO Q50

• Blankà SKIP TO Q49

47. Other tool(s) – please specify: ____________________________________à CONTINUE WITH Q49

47. At your health center, in a typical week, how many of your visits use telemedicine?

• None

• Some

• Most

• All

• Blank

Continue with Q50

47. At your health center, what, if any, issues affect your use of telemedicine?

Note: Select all that apply.

• Limited Internet access and/or speed issues

• Telemedicine platform not easy to use

• Telemedicine isn’t appropriate for my specialty/type of patients

• Limitations in patients’ access to technology (e.g., smartphone, computer, tablet, Internet)

• Patients’ difficulty using technology/telemedicine platform

• Improved reimbursement and relaxation of rules related to use of telemedicine visits

• Blank

Continue with Q51

_{Payment Information}

NCHS is offering participating health centers a one-time set-up fee of $10,000 (paid in two installments) to help with transmitting EHR data as required by NAMCS participants.

47. _{Please provide the following information to indicate to whom the $10,000 set-up fee checks should be mailed to.}

_{Payee (Health Center Name): [HC_NAME] [C]}

_{Payee Point of Contact} Name (Mr./Ms./Miss/Mrs./Dr.): [PAY1_SALUTE] [C] [PAY1_FIRST] [C] [PAY1_LAST] [C]

_{Attn: [}PAY1_ATTN_{] [C]}

_{Job Title: [}PAY1_TITLE_{] [C]}

_{Address: [}PAY1_STREET_{] [C]}

_{City/State/ZIP Code: [}PAY1_CITY_{] [C] / [}PAY1_STATE_{] [C] / [}PAY1_ZIP_{] [C]}

_{Telephone Number: [}PAY1_PHONE_{] [C] Extension: [PAY1_EXT] [C]}

_{E-mail: [}PAY1_EMAIL_{] [C]}

Thank you for agreeing to participate in NAMCS and for completing the Facility Interview Questionnaire. If you have any additional questions, please reach out to the NAMCS Health Center Support Team by telephone at 1-800-307-0134 (toll-free) or 301-458-4050 (local) or email NAMCSHealthCenters@cdc.gov.

END INTERVIEW.

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