Log sheet

PATIENT PERCEPTIONS OF THE DELIVERY OF HEALTH CARE

THROUGH THE USE OF AN ELECTRONIC HEALTH RECORD

Patient Recruitment Log

Interviewer Name: ___________________________ Date: ____/___/_______

Practice Name: ______________________________ Practice Location: _________________________

Practice number: _____ EHR or Paper? Sheet Number: ____ of _____ for this practice

			Interviewer’s best guess
#	Time	For each patient in waiting area	Age	Gender	Race
		[ ] Did not approach – Reason [ ] Ineligible – circle one: age, new patient [ ] Completed questionnaire, ID _______ EHR practices only, if refused survey: [ ] Refused F.G. – Reason: _____ [ ] F.G. card number _____ Refused – Reason [ ] Before appt., elig. unk. [ ] Before appt., eligible [ ] After appt., eligible	[ ] 18 - 64 [ ] 65+	[ ] Female [ ] Male	[ ] Hisp/Latino [ ] White [ ] Afr Amer. [ ] Asian [ ] Other
			Notes to remember R for after appt:
		[ ] Did not approach – Reason [ ] Ineligible – circle one: age, new patient [ ] Completed questionnaire, ID _______ Refused – Reason [ EHR practices only, if refused survey: [ ] Refused F.G. – Reason: _____ [ ] F.G. card number _____ ] Before appt., elig. unk. [ ] Before appt., eligible [ ] After appt., eligible	[ ] 18 - 64 [ ] 65+	[ ] Female [ ] Male	[ ] Hisp/Latino [ ] White [ ] Afr Amer. [ ] Asian [ ] Other
			Notes to remember R for after appt:
		[ ] Did not approach – Reason [ ] Ineligible – circle one: age, new patient [ ] Completed questionnaire, ID _______ Refused – Reason [ EHR practices only, if refused survey: [ ] Refused F.G. – Reason: _____ [ ] F.G. card number _____ ] Before appt., elig. unk. [ ] Before appt., eligible [ ] After appt., eligible	[ ] 18 - 64 [ ] 65+	[ ] Female [ ] Male	[ ] Hisp/Latino [ ] White [ ] Afr Amer. [ ] Asian [ ] Other
			Notes to remember R for after appt:
		[ ] Did not approach – Reason [ ] Ineligible – circle one: age, new patient [ ] Completed questionnaire, ID _______ EHR practices only, if refused survey: [ ] Refused F.G. – Reason: _____ [ ] F.G. card number _____ Refused – Reason [ ] Before appt., elig. unk. [ ] Before appt., eligible [ ] After appt., eligible	[ ] 18 - 64 [ ] 65+	[ ] Female [ ] Male	[ ] Hisp/Latino [ ] White [ ] Afr Amer. [ ] Asian [ ] Other
			Notes to remember R for after appt:
		[ ] Did not approach – Reason [ ] Ineligible – circle one: age, new patient [ ] Completed questionnaire, ID _______ Refused – Reason [ EHR practices only, if refused survey: [ ] Refused F.G. – Reason:_____ [ ] F.G. card number _____ ] Before appt., elig. unk. [ ] Before appt., eligible [ ] After appt., eligible	[ ] 18 - 64 [ ] 65+	[ ] Female [ ] Male	[ ] Hisp/Latino [ ] White [ ] Afr Amer. [ ] Asian [ ] Other
			Notes to remember R for after appt:

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