Form 0920-0234 NAMCS Provider Facility Interview (PFI)

Attachment L:

NAMCS Provider Facility Interview (PFI)

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.

Provider and Facility Data Elements
In addition to visit data, we are requesting the following data for each sampled PI provider.
Item #	REQUESTED DATA	INSTRUCTIONS/COMMENTS	EXAMPLES OF POSSIBLE ANSWER CHOICES
1	NAMCS ID	Use ID provided for each individually sampled provider	123456
2	Is sampled provider a MD, DO, or (advanced practice provider type)	Must be MD, DO, or (advanced practice provider type)	MD DO (advanced practice provider type) Group/practice (skip to 5) other
3	We have your specialty as: [INSERT SPECIALTY HERE] Is this correct?	Select only one	a. Yes (Skip to question 5) b. No
4	What is your specialty?	Specify verbatim at right
5	This survey asks about outpatient, office-based care, that is, care for patients receiving health services without admission to a hospital or other facility. Do you directly provide any outpatient, office-based care?	Select only one	a. Yes (Skip to next question 7) b. No
6	Why are you not currently providing any direct patient care?	Select only one then (Please exit the survey)	a. Engaged in research, teaching, and/or administration b. Once provided direct care but now retired c. Once provided direct patient care but temporarily not practicing (duration 3+ months) d. Now not licensed/Never licensed e. Something else (please specify): _____________________________
7	Overall, at how many locations do you see outpatient, office-based patients in a typical week? A typical week is defined as a week with a typical caseload, with no holidays, vacations, or conferences.	Specify verbatim at right
8	Do you see outpatient, office-based patients in any of the following settings? SELECT ALL THAT APPLY.	SELECT ALL THAT APPLY. If you see patients in any of the 1-10 settings, go to next question. If you select only 11, 12, 13, 14, 15 or 16 go to, please exit the survey	1) Private solo or group practice 2) Freestanding clinic or Urgent Care Center (e.g., Concentra Urgent Care, Patient First, NextCare Urgent Care, FastMed Urgent Care) 3) Health Center (e.g., Federally Qualified Health Center [FQHC], federally funded clinics or “look-alike” clinics) 4) Mental health center 5) Government clinic that is not federally funded (e.g., state, county, city, maternal and child health, etc.) 6) Family planning clinic (including Planned Parenthood) 7) Integrated Delivery System, Health maintenance organization, health system or other prepaid practice (e.g., Kaiser Permanente) 8) Faculty practice plan (an organized group of physicians that treats patients referred to an academic medical center) 9) Retail health clinic (e.g., CVS MinuteClinic, Walgreen’s Healthcare Clinics, Kroger’s Little Clinic) 10) Hospital outpatient department 11) Hospital emergency department 12) Ambulatory surgery center/surgicenter 13) Industrial outpatient facility 14) Federal government clinics (e.g., Veterans Affairs, military only clinics) 15) Institutional facility 16) None of the above
9	At which of the outpatient, office-based setting (1-10) in Question 5 do you see the most patients in a typical week? WRITE THE NUMBER LOCATED NEXT TO THE SELECTION MADE.	Specify verbatim at right For the rest of the survey, we will refer to this as “your reporting location.”
10	Provider's NPI number	Specify verbatim at right	0123456789
11	Reporting Location state	Enter State	CA
12	Reporting Location zip	Must be 5 digits.	55555
13	Reporting Location email	Specify verbatim at right
14	Reporting Location County	Enter County
16	Number of visits in a typical week of practice-reporting location?	Only include visits from reporting location for a typical week of practice.	30
17	Number of days worked at reporting location during a typical week?	Include number of days sampled physician worked only at reporting location during a typical week.	3