Form 0920-0234 NAMCS Tracing Questionnaire (Survey year 2025 & 2027)

Attachment F:

NAMCS Tracing Questionnaire

Form Approved:

OMB No. 0920-0234

NOTICE - Public reporting burden of this collection of information is estimated to average 10 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.

Exp. Date xx/xx/20XX

Script for confirming the sampled physician’s or PA’s mailing address and email address.

1. Hello, my name is [insert name] and I am calling from the [placeholder]. Is this the office of insert sampled provider’s name?

• Yesà <GO TO II>

• Yes, physician/PA speaking <GO TO II>

• Yes, but name changed <GO TO II>

• Yes, but this is not a good time/can I take a message?<GO TO III>

• No <GO TO IV>

IF DR./PA [insert sampled provider’s name] STILL WORKS AT THAT OFFICE:

2. I’m calling on behalf of the Centers for Disease Control and Prevention’s National Center for Health Statistics regarding a survey Dr./PA [insert sampled provider’s name] has been selected to take part in starting next year. Before that happens, I would like to confirm the best mailing address where Dr./PA [insert sampled provider’s name] works.

   • A. We have here that [insert complete office address] is the best mailing address. Is this correct?

• YESà <GO TO A1a>

  • A1a. IF THIS MAILING ADDRESS IS CORRECT: Great, thank you.

• CHECK OFF PRIMARY MAILING ADDRESS

• <GO TO A2>

• NOà <GO TO A1b>

• A1b. IF THIS MAILING ADDRESS IS INCORRECT: What is the best mailing address for Dr./PA [insert sampled provider’s name]?

  • CHECK OFF ALTERNATE MAILING ADDRESS OR FILL IN UPDATED MAILING ADDRESS

  • <GO TO A2>

• A2. I would also like to confirm the best work email address for Dr./PA [insert sampled provider’s name].

• A2a. IF EMAIL ADDRESS IS AVAILABLE: Is [insert email address] the best email address?

• YESà <GO TO i>

• i. IF THIS EMAIL ADDRESS IS CORRECT: Great, thank you.

  • CHECK OFF EMAIL ADDRESS

  • That’s all the information I need. Thank you for your time and have a nice day.

  • CLOSE

• NO à <GO TO ii>

• ii. IF THIS EMAIL ADDRESS IS INCORRECT: What is the best email address for Dr./PA [insert sampled provider’s name]?

  • CHECK OFF ALTERNATE EMAIL ADDRESS OR FILL IN UPDATED EMAIL ADDRESS

  • Great, that is all the information I need. Thank you for your time and have a nice day.

• CLOSE

• A2b. IF EMAIL ADDRESS IS NOT AVAILABLE: What is the best email address for Dr./PA [insert sampled provider’s name]?

  • FILL IN EMAIL ADDRESS

  • That’s all the information I need. Thank you for your time and have a nice day.

  • CLOSE

TO LEAVE A MESSAGE WITH SOMEONE AT DR./PA [insert sampled provider’s name]’S OFFICE:

3. I’m calling from the [placeholder] on behalf of the Centers for Disease Control and Prevention’s National Center for Health Statistics. Dr./PA [insert sampled provider’s name] has been selected to take part in a survey. We would like to confirm the best mailing address and email address for Dr./PA [insert sampled provider’s name] prior to data collection. I’d like to ask that they please call us back toll-free at [placeholder phone number].

IF DR./PA [insert sampled provider’s name] DOES NOT WORK AT THAT OFFICE:

4. I’m calling on behalf of the Centers for Disease Control and Prevention’s National Center for Health Statistics regarding a survey Dr./PA [insert sampled provider’s name] has been randomly selected to take part in starting next year. Before that happens, I would like to confirm the best mailing address where Dr./PA [insert sampled provider’s name] works.

   • B1. Do you have an updated work address for Dr./PA [insert sampled provider’s name]?

• YES

  • FILL IN UPDATED MAILING ADDRESS.

  • <GO TO B2>

• NO <GO TO B2>

• [insert sampled provider’s name] has retired

• SELECT CALL RESOLUTION 'Retired'

• Okay, thank you for your time and have a nice day.

• CLOSE

• [insert sampled provider’s name] is deceased

• SELECT CALL RESOLUTION 'Deceased'

• Please respond compassionately and relay your sympathy. We will do the best we can to ensure their office does not receive any additional mailings or emails regarding this survey. If they do happen to receive another mailing or email, please accept our sincerest apology in advance.

• CLOSE

• B2. Do you have a work email address for Dr./PA [insert sampled provider’s name]?

• YES

• FILL IN EMAIL ADDRESS

• Great, thank you for your time and have a nice day.

  • CLOSE

• NO

• Okay, thank you for your time and have a nice day.

  • CLOSE

VOICEMAIL MESSAGES

FOR MESSAGE LEFT ON VOICEMAIL:

Hello, my name is [insert name] and I’m calling from the [placeholder] on behalf of the Centers for Disease Control and Prevention’s National Center for Health Statistics. Dr./PA [insert sampled provider’s name] has been selected to take part in a survey. We would like to confirm the best mailing address and email address for Dr./PA [insert sampled provider’s name] prior to data collection. Please call us back toll-free at [placeholder phone number]. Thank you.