Form 2 One-Month Patient Follow-up Telephone Call

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Attachment C:

One-Month Patient Follow-up Telephone Call

1. Introduction

RA:

Hello Mr./Ms. [insert patient’s name]. My name is [insert your name], and I am a research assistant from the Johns Hopkins Hospital Emergency Department. I am calling to follow up on your visit to the emergency at Johns Hopkins a month ago on [insert date]. We would like to check and see if the interventions that were given to you during your emergency room visit met your needs.

I would like to ask you a few questions, which will take about 5 minutes. Is now a good time to talk?

Patient:

[Answers yes or no]

RA:

[If patient answers “yes,” then continue onto section B.]

[If patient answers “no,” then ask if there is a better time for you to call back.]

2. Follow-up Questions

1. What did the provider say was the cause of your illness?

Patient’s Response: _______________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

2. Did the provider tell you to take any medications?

Patient’s Response: _______________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

3. How did he or she tell you to use each of them?

Patient’s Response: _______________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

4. What are some of the worrisome symptoms the provider told you to pay attention to?

Patient’s Response: _______________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

5. What did the provider tell you about to follow up (with whom and when)?

Patient’s Response: _______________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

3. Close

RA:

Thank you, Mr./Ms. [insert patient’s name] for taking the time to answer these questions. You have answered all of the follow-up questions that we had. Have a great day.

Public reporting burden for this collection of information is estimated to average 10 minutes per response, the estimated time required to complete the survey. 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: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.