US PHS PPAC Survey on Access to Health Care

Attachment 2 PPAC Survey Instrument

Form Approved

OMB No. 0920-1027

Expiration Date: 08/31/2017

Welcome to the US PHS PPAC survey on access to health care

Thank you for agreeing to take part in this brief but important survey measuring access to healthcare among PHS medical officers. The survey was developed by the PPAC Mental Health Subcommittee as a follow-up of a similar study done six years ago. We hope to identify actionable barriers to care. The survey should only less than 10 minutes to complete. All answers that you provide will be confidential and we are not collecting personally identifiable information.

Public reporting burden for this collection of information is estimated to average 10 minutes per survey completion, which includes the time required for reviewing instructions and completing 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 CDC, Project Clearance Officer, 1600 Clifton Road, MS E-11, Atlanta, GA 30333, ATTN: PRA (0920-1207). Do not send the completed form to this address.

DEMOGRAPHIC QUESTIONS:

What is your current duty status?

• Active Duty

• Retired

How old are you (in years)?

• 20-29

• 30-39

• 40-49

• 50 or older

What is your current rank?

• O-1 to O-3

• O-4 to O-6

• O-7 or above

By which agency are you employed?

• Agency for Healthcare Research and Quality

• Agency for Toxic Substances and Disease Registry

• Assistant Secretary for Health

• Assistant Secretary for Preparedness and Response

• Bureau of Prisons

• Centers for Disease Control and Prevention

• Centers for Medicare and Medicaid Services

• Coast Guard

• Department of Defense

• Food and Drug Administration

• Health Resources and Services Administration

• Immigration and Naturalization Service

• Indian Health Service

• Substance Abuse and Mental Health Services Administration

• Other

In which region are you currently based?

• Northeast Region: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont

• Midwest Region: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin

• South Region: Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia

• West Region: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming

• Other

SURVEY QUESTIONS

1. Do you know of any situation in the past 12 months where a PHS medical officer or a family member of a PHS medical officer attempted to access medical care?

• Yes

• No

2. Do you know of any situation in the past 12 months where a PHS medical officer or a family member of a PHS medical officer had difficulty accessing medical care?

• Yes

• No

3. Do you know of any situation in the past 12 months where a PHS medical officer or a family member of a PHS medical officer attempted to access mental health care?

• Yes

• No

4. Do you know of any situation in the past 12 months where a PHS medical officer or a family member of a PHS medical officer had difficulty accessing mental health care?

• Yes

• No

5. Do you know of any situation in the past 12 months in which a mental health issue appeared to be affecting the job performance of one or more PHS medical officers?

• Yes

• No