Form Approved
OMB No. 0990-
Exp. Date XX/XX/20XX
Patient Perceptions of HER
PATIENT RECRUITMENT SCRIPT
Hello, my name is ____ , and I work for a company called Mathematica Policy Research. We are conducting a study for the U.S. Department of Health and Human Services (the Office of the National Coordinator for Health Information Technology).
We’d like to request your help with our study of patients to learn about their experiences and perception of their health care. This practice has agreed to let Mathematica speak to patients while they wait to see the doctor, to invite them to volunteer for the study.
We are hoping that you will agree to participate in this study, which is short and not difficult. If you are eligible and choose to participate, you will be asked to fill out a 15-minute questionnaire after you have been seen by your health care provider. You will be given a $10 gift card to VENDOR NAME to thank you for your time in completing the questionnaire.
Would you be willing to help us with this study?
YES – GO TO ELIGIBILITY SCREENING
NO – IN EHR PRACTICES, GO TO FOCUS GROUP RECRUITING/SCREENING, page 2.
IN PAPER RECORDS PRACTICES Thank you for your time. (END and MARK LOG SHEET)
ELIGIBILITY SCREENING
Great, thanks. I have just three questions to see if you are eligible to participate in this study.
Are you 18 years of age or older?
YES (go to 2)
NO (go to SURVEY INELIGIBLE)
Are you being seen by a health care provider in this practice today or are you accompanying someone who is seeing a provider?
BEING SEEN (go to 3)
ACCOMPANYING SOMEONE I need to interview the person who is being seen by the provider today. (Try to recruit/screen that person)
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990- . The time required to complete this information collection is estimated to average 2 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
Have you been a patient at this practice for 12 months or longer?
YES (go to SURVEY ELIGIBLE)
NO (go to SURVEY INELIGIBLE)
SURVEY ELIGIBLE
Thank you again for your willingness to participate. When you have finished your visit with the health care provider, I will give you the questionnaire to complete. The questionnaire is anonymous; we do not collect names. In the meantime, here is some additional information about the study.
HAND LETTER AND FACT SHEET. MARK LOG SHEET.
SURVEY INELIGIBLE
I’d like to thank you for your willingness to participate. Unfortunately, we are only recruiting patients who have a visit with a health care provider today, who are 18 years of age and older, and who have been a patient at this practice for 12 months or longer. Thank you again for your time.
END and MARK LOG SHEET
FOCUS GROUP RECRUITMENT SCRIPT – IN EHR PRACTICES ONLY
We are also looking for volunteers to participate in a focus group discussion of the ways that electronic health records affect medical care. Participants will receive a $40 gift card as payment. The discussion will take about an hour and a half and will be held on [DATE] at [TIME]. We will be meeting at [LOCATION]. Would you be interested in possibly participating in the discussion?
IF YES: Thank you. Please fill out this card with your contact information on one side and three short items on the other side, and one of our research staff members will be in touch with you in the next couple of days.
HAND POSTCARD TO COMPLETE; MARK LOG SHEET
IF NO: Thank you anyway. We appreciate your taking the time to speak with us.
END and MARK LOG SHEET
H.
| File Type | application/msword |
| File Title | Form Approved |
| Author | Premini |
| Last Modified By | DHHS |
| File Modified | 2010-04-21 |
| File Created | 2010-04-21 |