Form
Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX
Attachment D:
Three-Month Patient Follow-up Telephone Call
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 three months ago on [insert date]. Is now a good time to talk? This will take less than 5 minutes.
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.]
Follow-up Questions
When you visited the emergency room three months ago, you did not have insurance. Have been able to get insurance since your visit three months ago?
Yes [Skip to question #3 if patient answers “yes.”]
No
Patient’s comments: _________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
What has prevented you from getting insurance since your visit three months ago?
Patient’s answer: ____________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Is there anything further that we can assist you with regarding either your insurance or your visit to the emergency room three months ago?
Patient’s answer: ____________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
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 5
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.
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | jhu |
File Modified | 0000-00-00 |
File Created | 2021-01-28 |