OMB #: 0925-0593
OMB Expiration Date: 07/31/ 2013
Provider Based Sampling Frame Questionnaire Harris County, Phase 2e
Provider Based Sampling Frame Questionnaire
(Harris County)
Event: |
Provider Based Recruitment |
Participant: Respondent: |
Provider Provider |
Domain: |
Questionnaire |
Type of Document: Allowable Mode: Allowable Method: |
Self-Administered Questionnaire In Person, Telephone, Mail PAPI |
Recruitment Groups: |
PBS |
Version: |
1.0 |
Release:
|
MDES 3.0
|
Provider-Based Sampling Frame Questionnaire |
DEFINITIONS:
|
PSU ID # (Harris County): 20000262 Practice #: Location #: |
M M / D D / Y Y Y Y |
__________________________________________________________________________________ |
Street Address: ______________________________________________________________________ Suite/Unit#: ______________________________________________________________________ City: ______________________________________________________________________ State: Zip Code: - |
Name: ______________________________________________________________________ Position/Role: ______________________________________________________________________ Street Address: ______________________________________________________________________ Suite/Unit#: ______________________________________________________________________ City: ______________________________________________________________________ State: Zip Code: - Email Address: ______________________________________________________________________ Phone Number: () - Ext: Preferred method of contact: ____________________________________________ |
Total providers |
(The total number of providers listed below should equal the number of total providers in Question #6.) Number of Obstetrics/Gynecology (OB/GYN) providers Number of Obstetrics (OB) providers only Number of Gynecology (GYN) providers only Number of Family Medicine Providers (that provide prenatal care) Number of Midwives Number of Other Providers. (such as Nurse Practitioners) Other (Specify): _____________________________________________________________ |
Private with no health system or university affiliation Private with health system or university affiliation Health system with no university affiliation Academic medical center Federally qualified health center Public clinic with no university/academic affiliation Public clinic with university/academic affiliation Other. (Specify): ________________________________________________________ |
For Questions #9 through #11 below, if you do not have precise numbers, please provide your best estimates. |
All prenatal care visits |
First prenatal care visits |
First prenatal care visits of Harris county residents |
For the list of payers that follows, regarding the approximate payer mix for this practice location/office, list the percent for each payer. Please provide an estimate if the exact percent is not known. The total percentage for all payers cannot be greater than 100%. Tricare: % Medicaid: % Commercial: % HMO: % Self Pay: % |
For the first prenatal care visit patients at this medical practice location/office, please indicate the percent of those patients with the following observed or reported ethnicity . Please provide an estimate if the exact percent is not known.
Hispanic, Latina, or Spanish origin % |
Using the following categories, list the observed or reported primary race of patients at this medical practice location/office. Again, the focus is on patients seen at the first prenatal care visit. Please provide an estimate if the exact percent is not known. The total percentage for all races cannot be greater than 100%.
White: % Black or African American: % American Indian or Alaska Native: % Asian: % Native Hawaiian/ other Pacific Islander: % |
Using the following options, indicate the reported primary language of first prenatal care visit patients at this medical practice location/office. Please estimate if the exact percent is not known. The total percentage for all languages cannot be greater than 100%.
English: % Spanish: % Other: % (If other, Specify:) __________________________________________________________________ |
For the following groups, indicate the reported age of first prenatal care visit patients at this medical practice location/office. Please provide an estimate if the exact percent is not known. The total percentage for all ages cannot be greater than 100%.
Patients under 20 years old: % Patients between 20 – 24 years old: % Patients between 25 – 29 years old: % Patients 30 or more years old: % |
___ Yes ___ No → End of Questionnaire. |
|
Same as Question 5 → Go to Question 20. Name: _______________________________________________________________________ Position/Role: _______________________________________________________________________ Street Address: _______________________________________________________________________ Suite/Unit#: _______________________________________________________________________ City: ________________________________________________________________________ State: ________________________________________________________________________ Zip Code: ________________________________________________________________________ Email Address: ________________________________________________________________________ Phone Number: () - Ext:
Preferred mode of contact: ______________________________________________ |
Total Locations |
Total Births |
Total Births In Harris County |
Public reporting burden for this collection of information is estimated to average 20 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 27892-7974, ATTN: PRA (0925-0593*). Do not return the completed form to this address.
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Modified | 0000-00-00 |
File Created | 2021-01-30 |