Recruitment for State Surveys of Endoscopic Capacity

Form Approved

OMB No. 0920-0539

Exp. xx/xx/xxxx

Attachment F2 State SECAP II

Screening Telephone Call to Identify the Appropriate

Survey Respondent

For each facility to be surveyed, a screening telephone call will be made to (1) confirm that the facility is eligible for inclusion in the study and (2) obtain the name and address of the individual who is most knowledgeable about the use of the endoscopic equipment. The questions to be asked during the screening call will vary by practice setting. The screening survey will be administered as a computer-assisted telephone interview. As a result, data entry will be performed as part of the interview process and the skip-logic will be electronic.

The following burden statement will be available to be read to the person responding to the call if they ask for this information.

Public reporting burden of this collection of information is estimated to average 5 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 Reports Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0539).

Questions 1-4 will be asked of the individual who answers the phone at the practice site.

1. Hello, my name is (INTERVIEWER NAME). I am calling from the Battelle Centers for Public Health Research and Evaluation in Seattle, Washington. I am calling on behalf of the Centers for Disease Control and Prevention (and the State Name Department of Public Health). They are conducting a survey of facilities that perform endoscopy for the detection of colorectal cancer. Am I calling (CONFIRM NAME AND ADDRESS)?

IF YES, CONTINUE WITH QUESTION 2

IF NO, RECORD NAME AND ADDRESS BELOW BEFORE

CONTINUING WITH QUESTION 2

___________________________

____________________________

____________________________

2. Does this practice perform flexible sigmoidoscopy or colonoscopy to detect colorectal cancer in adults?

yes

no

don’t know

If NO to question 2, conclude the interview by saying: “I’m sorry, but our study is focusing on practice sites that perform colorectal cancer screening in adults. Thank you very much for your time.”

If DON’T KNOW, ask to speak to someone who might know: “Is there someone else there who might know? May I speak with him/her?”

3. Are the flexible sigmoidoscopies or colonoscopies performed at this site or somewhere else?

yes, performed at this site

no, performed elsewhere

don’t know

If NO to question 3, conclude the interview by saying: “I’m sorry, but our study is focusing on practice sites that perform colorectal cancer screening in adults. Thank you very much for your time.”

If DON’T KNOW, ask to speak to someone who might know: “Is there someone else there who might know? May I speak with him/her?”

4. Can you please tell me which of the following best describes this practice site?

Private Practice

Ambulatory endoscopy or surgery center

Hospital

IF THE PRACTICE SITE IS A HOSPITAL, THE INTERVIEWER WILL CONTINUE WITH PART A

IF THE PRACTICE SITE IS AN ANBULATORY ENDOSCOPY/SURGERY CENTER OR A PRIVATE PRACTICE, THE INTERVIEWER WILL CONTINUE WITH PART B

PART A—TO BE ASKED IF THE PRACTICE SITE IS A HOSPITAL

Please connect me with the Gastroenterology Department. If the respondent indicates that the hospital does not have a Gastroenterology Department, ask to be connected to the department where sigmoidoscopy and/or colonoscopy are performed.

QUESTIONS FOR THE HOSPITAL GASTROENTEROLOGY DEPARTMENT

When the interviewer reaches the Hospital Gastroenterology Department, read the following:

Hello, my name is (INTERVIEWER NAME) and I am calling from the Battelle Centers for Public Health Research and Evaluation in Seattle, Washington. I am calling on behalf of the Centers for Disease Control and Prevention (and the State Name Department of Public Health). They are conducting a survey of facilities that perform endoscopy for the detection of colorectal cancer. May I please speak with the charge nurse in the endoscopy suite? If the charge nurse is not available, obtain a name and telephone number of the charge nurse to call at a later time.

When the interviewer reaches the charge nurse, read the following:

5. Hello, my name is (INTERVIEWER NAME) and I am calling from the Battelle Centers for Public Health Research and Evaluation in Seattle, Washington. I am calling on behalf of the Centers for Disease Control and Prevention (and the State Name Department of Public Health). They are conducting a survey of facilities that perform endoscopy for the detection of colorectal cancer. Does this hospital perform flexible sigmoidoscopy or colonoscopy to detect colorectal cancer in adults?

yes

no

If NO to question 5, conclude the interview by saying: “I’m sorry, but our study is focusing on hospitals that perform colorectal cancer screening in adults. Thank you very much for your time.”

6. I am trying to identify all the sites within this hospital where sigmoidoscopy and/or colonoscopy are performed to detect colorectal cancer in adults. As the charge nurse in the endoscopy suite, I thought you might best be able to help us identify these sites. Can you please tell me whether or not flexible sigmoidoscopy or colonoscopy are performed in the following divisions or departments in your hospital? I am only interested in departments that perform these procedures in adults. (Read and record all that apply)

Gastroenterology department

General surgery department

Colorectal surgery department

Family practice department

General internal medicine department

Operating room

Satellite clinics (list all satellite clinics)

Other (specify)___________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

7. We would like to send a survey to the person who knows the most about the numbers of flexible sigmoidoscopies and colonoscopies that are being performed in this department and who is performing these procedures. Most likely this is the physician who is in charge of endoscopy at this facility. Can you please tell me the name of that person? If there is no physician in charge of endoscopy at the facility, ask if there is a nurse or an administrator who could provide this information. Confirm the spelling of the name, title, and specialty of the person (to determine if the cover letter and envelope should be addressed to Dr., Mr. or Ms.).

Name: __________________________________________

Title: __________________________________________

Specialty: __________________________________________

8. What is the Federal Express address and telephone number for Dr./Mr./Ms. (PERSON IDENTIFIED IN QUESTION 7)? Be sure that the address includes the name of the practice site (e.g., name of the physician practice, hospital department, clinic, surgical center).

Practice Site: _________________________________________

Address: _________________________________________

_________________________________________

City, State, Zip Code: _________________________________________

Telephone Number: _________________________________________

9. Is the mailing address for Dr./Mr./Ms. (PERSON IDENTIFIED IN QUESTION 7) the same as his/her Federal Express address? If not, what is his/her mailing address?

Address: _________________________________________

_________________________________________

City, State, Zip Code: _________________________________________

Conclude the interview with the Gastroenterology Department charge nurse by saying: “That is all the information I need at the moment. Thank you very much for your time and assistance. You have been very helpful. Good-bye.”

QUESTIONS FOR OTHER HOSPITAL SITES THAT PERFORM ENDOSCOPY

When the interviewer reaches a hospital department other than the Gastroenterology Department, read the following:

Hello, my name is (INTERVIEWER NAME) and I am calling from the Battelle Centers for Public Health Research and Evaluation in Seattle, Washington. I am calling on behalf of the Centers for Disease Control and Prevention (and the State Name Department of Public Health). They are conducting a survey of facilities that perform endoscopy for the detection of colorectal cancer. May I please speak with the charge nurse in the department/division/clinic? If the charge nurse is not available, obtain a name and telephone number of the charge nurse to call at a later time.

When the interviewer reaches the charge nurse, read the following:

10. Hello, my name is (INTERVIEWER NAME) and I am calling from the Battelle Centers for Public Health Research and Evaluation in Seattle, Washington. I am calling on behalf of the Centers for Disease Control and Prevention (and the State Name Department of Public Health). They are conducting a survey of facilities that perform endoscopy for the detection of colorectal cancer. Does [NAME OF THE HOSPITAL DEPARTMENT/DIVISION/ CLINIC] perform flexible sigmoidoscopy or colonoscopy to detect colorectal cancer in adults?

yes

no

If NO to question 10, conclude the interview by saying: “I’m sorry, but our study is focusing on hospital departments that perform colorectal cancer screening in adults. Thank you very much for your time.”

11. We would like to send a survey to the person who knows the most about the numbers of flexible sigmoidoscopies and colonoscopies that are being performed and who are performing these procedures. Most likely this is the physician who is in charge of endoscopy at this facility. Can you please tell me the name of that person? If there is no physician in charge of endoscopy at the facility, ask if there is a nurse or an administrator who could provide this information. Confirm the spelling of the name, title, and specialty of the person (to determine if the cover letter and envelope should be addressed to Dr., Mr. or Ms.).

Name: __________________________________________

Title: __________________________________________

Specialty: __________________________________________

12. What is the Federal Express address and telephone number for Dr./Mr./Ms. (PERSON IDENTIFIED IN QUESTION 11)? Be sure that the address includes the name of the practice site (e.g., name of the hospital department, outpatient clinic, surgical center).

Practice Site: _________________________________________

Address: _________________________________________

_________________________________________

City, State, Zip Code: _________________________________________

Telephone Number: _________________________________________

13. Is the mailing address for Dr./Mr./Ms. (PERSON IDENTIFIED IN QUESTION 11) the same as his/her Federal Express address? If not, what is his/her mailing address?

Address: _________________________________________

_________________________________________

City, State, Zip Code: _________________________________________

Conclude the interview with the charge nurse by saying: “That is all the information I need at the moment. Thank you very much for your time and assistance. You have been very helpful. Good-bye.”

PART B—TO BE ASKED IF THE PRACTICE SITE IS AN AMBULATORY ENDOSCOPY/SURGERY CENTER OR A PRIVATE PRACTICE

14. We would like to send a survey to the person who knows the most about the numbers of flexible sigmoidoscopies and colonoscopies that are being performed and who is performing these procedures. Most likely this is the physician who is in charge of endoscopy at this facility. Can you please tell me the name of that person? If there is no physician in charge of endoscopy at the facility, ask if there is a nurse or an administrator who could provide this information. Confirm the spelling of the name, title, and specialty of the person (to determine if the cover letter and envelope should be addressed to Dr., Mr. or Ms.).

Name: __________________________________________

Title: __________________________________________

Specialty: __________________________________________

15. What is the Federal Express address and telephone number for Dr./Mr./Ms. (PERSON IDENTIFIED IN QUESTION 14)? Be sure that the address includes the name of the practice site (e.g., name of the physician practice, clinic, surgical center).

Practice Site: _________________________________________

Address: _________________________________________

_________________________________________

City, State, Zip Code: _________________________________________

Telephone Number: _________________________________________

16. Is the mailing address for Dr./Mr./Ms. (PERSON IDENTIFIED IN QUESTION 14) the same as his/her Federal Express address? If not, what is his/her mailing address?

Address: _________________________________________

_________________________________________

City, State, Zip Code: _________________________________________

Conclude the interview by saying: “That is all the information I need at the moment. Thank you very much for your time and assistance. You have been very helpful. Good-bye.”