Screener

APPENDIX B

SCREENING / INTRODUCTION: Pretest

[Programmer: On screen:

This research is authorized by Section 1701(a)(4) of the Public Health Service Act (42 U.S.C. 300u(a)(4)). Confidentiality is protected by 5 U.S.C. 552(a) and (b) and 21 CFR part 20.

OMB Control No. ____. Expires xx/xx/xx. ]

Thank you for agreeing to participate in this study today. Make sure you are comfortable and can read the screen from where you sit. This study will take about 20 minutes to complete. We ask you to please complete the study in one sitting (without taking any breaks) in order to avoid distractions.

This study is about direct-to-consumer advertising.

First, please answer the following questions.

S1. Which of the following best describes your profession?

_____Medical Doctor/Doctor of Osteopathy [CONTINUE]

_____Physician Assistant [CONTINUE]

_____Nurse Practitioner [CONTINUE]

_____Other [TERMINATE]

S2a. Do you consider yourself a primary care provider or specialist?

_____Primary Care Provider [CONTINUE TO S2b] [ASSIGN AS PRIMARY CARE]

_____Specialist [CONTINUE TO S2c] [ASSIGN AS SPECIALIST]

S2b. Which of the following best describes your practice?

_____Family Practice [CONTINUE]

_____General Practice [CONTINUE]

_____Internal Medicine [CONTINUE]

_____OB-GYN [CONTINUE]

S2c. Which of the following categories best describes your primary area of specialization:

_____Pediatrics [TERMINATE]

_____Allergy or Pulmonology [CONTINUE]

_____Psychiatry [CONTINUE]

_____Endrocrinology [CONTINUE]

_____Dermatology [CONTINUE]

_____Rheumatology [CONTINUE]

_____Cardiology [CONTINUE]

_____Otolaryngology [CONTINUE]

_____Urology [CONTINUE]

_____Neurology [CONTINUE]

_____Oncology[CONTINUE]

_____Gastroenterology [TERMINATE]

_____Podiatry [TERMINATE]

_____Pain management [CONTINUE]

_____OB-GYN [CONTINUE]

_____Other [TERMINATE]

S3. In what state is your practice based? ____________

[NPS AND PAS only answer S3a and S3b]

S3a. In the state where you work, do you have authority to prescribe medications?

_____Yes [CONTINUE]
_____No [TERMINATE]

S3b. Please choose the answer that best describes your level of prescribing authority (check all that apply):

_____ Unrestricted, unlimited [CONTINUE]

_____Only in conjunction with a medical doctor [CONTINUE]

_____Cannot prescribe controlled substances [CONTINUE]

_____Only as part of a Collaborative Drug Therapy Management (CDTM) agreement [CONTINUE]

_____Cannot prescribe medication [TERMINATE]

S4. In an average week, what percent of your time is spent on direct patient care, such as seeing patients and reviewing their medical records? If you are not sure, please provide your best guess.

_____% [IF LESS THAN 50%, TERMINATE]

S5. Which of the following best describes your primary type of practice:

___Office-based practice [CONTINUE]

___Hospital [TERMINATE]

___Nursing home or hospice care [TERMINATE]
___Veterans Affairs [TERMINATE]
___Research [TERMINATE]
___Other (specify):____________[TERMINATE]