Survey on Rural Community Wealth and Health Care Provision - Mail/web survey with health care providers_respondents

ANNEX F

HEALTH CARE PROVIDER QUESTIONNAIRE

ERS: Rural Community Wealth and Health Care Provision

PROVIDERS MAIL/WEB SURVEY

9/20/2013

Verification.
1. Are you currently working as a health care provider in [TOWN], [STATE]? 1 = Yes 2 = No If no, please return this survey in the envelope provided, so we can correct our records and do not continue to try to reach you. Thank you!
Your Background.
2. Your current role as a health care provider: 1 = Physician (MD or DO) 2 = Dentist 3 = Physician’s Assistant 4 = Nurse Practitioner 5 = Midwife 6 = Other: _____________________________	3. Your specialty: 1 = Family Practice, General Practice 2 = Internal Medicine 3 = OB/GYN 4 = Pediatrics 5 = Other: ____________________________
4. Where do you live in relationship to [TOWN]? 1 = Within city limits 2 = Within 2 miles of town 3 = 2 to 10 miles from town 4 = 10 to 20 miles from town 5 = 20 or more miles from town	5. Did you ever live in [TOWN] before you began working there as a health care provider? 1 = Yes 2 = No
6. Year you completed your highest level of medical/dental training: __ __ __ __	7. Year you began working as a health care professional in this community: __ __ __ __
8. Location of your medical/dental training: 1 = USA State: ___________________ 2 = Other country: ______________________	9. Did you spend any part of your residency, an internship, or externship in a rural area or a small town? (<20,000 pop.) 1 = Yes 2 = No
10. Location where you graduated from high school: 1 = USA State: ___________________ 2 = Other country: ______________________	11. Where did you primarily grow up? 1 = Farm/ranch, not in a town or city 2 = Town of less than 20,000 population 3 = City of 20,000 to 100,000 population 4 = City/Metropolitan area over 100,000 pop.

Your Current Practice.
12. Where is your current practice based? 1 = In a hospital 2 = In a clinic 3 = In an office setting 4 = In a retail business setting 5 = Other: ____________________________	13. Are you the sole owner, a part-owner, or an employee of your practice? 1 = Sole owner 2 = Part-owner 3 = Employee
14. Number of hours you work per week in [TOWN] (on average): ___ ___ hours/week	15. Number of hours you work per week in other communities (if any, on average): ___ ___ hrs/wk 0 = None
16. Which best describes your current on-call responsibilities? 1 = Do not have on-call responsibilities 2 = Acceptable on-call responsibilities 3 = Unacceptable on-call responsibilities	17. Do you have adequate professional coverage for your practice while you are on vacation? 1 = Yes 2 = No

Your Recruitment Experience.
18. How did you learn about the opportunity to work in this community? (Circle all that apply.) 1 = Family or friends 2 = Professional colleague 3 = School faculty or placement office 4 = Position announcement 5 = Town representative or organization 6 = Professional recruiter 7 = Someplace else: ______________________________
19. Was there a specific recruitment effort on the part of [TOWN] leaders to encourage you to work in this community? 1 = Yes 2 = No [If No or Unsure, please go to Q.21, next page.] 3 = Unsure, don’t remember
20. If yes, what did the recruitment entail? (Circle all that apply) 1 = Information provided by community (e.g., brochures, lists of services, etc.) 2 = Site visit for myself arranged by community 3 = Site visit for my spouse/children arranged by community 4 = Site visit for myself arranged by employer 5 = Site visit for my spouse/children arranged by employer 6 = Other (Describe below) _______________________________________________________________________________ _______________________________________________________________________________
Your Decision to Work in This Community.
21. How important to you were each of the following factors in your decision to practice in this community?
		Not Important				Neutral				Very Important
a.	Your own familiarity with this area		1	2			3	4			5
b.	Opportunities for your spouse or partner		1	2			3	4			5
c.	Relatives or friends are nearby		1	2			3	4			5
d.	Good place to raise a family		1	2			3	4			5
e.	Quality of schools		1	2			3	4			5
f.	Size of the town		1	2			3	4			5
g.	Recreational opportunities		1	2			3	4			5
h.	Natural amenities (climate, scenery, lakes/rivers/ocean, etc.)		1	2			3	4			5
i.	Cultural amenities (local arts, historical sites, cultural events, etc.)		1	2			3	4			5
j.	Social opportunities (churches, social organizations, etc.)		1	2			3	4			5
k.	Friendliness of the people		1	2			3	4			5
l.	Availability of goods and services		1	2			3	4			5
m.	Low taxes		1	2			3	4			5
n.	Low cost of living		1	2			3	4			5
o.	The need for health care providers in the community		1	2			3	4			5
p.	Recruitment efforts by the community		1	2			3	4			5
q.	Placement through a program (NHSC, visa waiver, etc.)		1	2			3	4			5
r.	Quality of medical facilities		1	2			3	4			5
s.	Quality of the medical community		1	2			3	4			5
t.	Opportunities for your professional growth/advancement		1	2			3	4			5
u.	Opportunity to own a practice		1	2			3	4			5
v.	Good financial package (salary, benefits, loan forgiveness, etc.)		1	2			3	4			5
w.	Reasonable workload		1	2			3	4			5
22. What is the most important reason why you chose to practice in this community?
23. What was the biggest drawback to choosing to practice in this community?

Your Decision to Stay in This Community.
24. How important to you are each of the following reasons for continuing to work in this community?
		Not Important				Neutral			Very Important
a.	Your family is settled there; don’t want to uproot them		1	2			3	4		5
b.	Your spouse or partner has a good job/career		1	2			3	4		5
c.	Relatives or friends are nearby		1	2			3	4		5
d.	Good place to raise a family		1	2			3	4		5
e.	Quality of schools		1	2			3	4		5
f.	Size of the town		1	2			3	4		5
g.	Recreational opportunities		1	2			3	4		5
h.	Natural amenities (climate, scenery, lakes/rivers/ocean, etc.)		1	2			3	4		5
i.	Cultural amenities (local arts, historical sites, cultural events, etc.)		1	2			3	4		5
j.	Your involvement in community activities		1	2			3	4		5
k.	Friendliness of the people, good friendships		1	2			3	4		5
l.	Availability of goods and services		1	2			3	4		5
m.	Low taxes		1	2			3	4		5
n.	Low cost of living		1	2			3	4		5
o.	The need for health care providers in the community, having a positive impact through your practice		1	2			3	4		5
p.	Efforts by the community to encourage you to stay		1	2			3	4		5
q.	Quality of the medical facilities		1	2			3	4		5
r.	Quality of the medical community		1	2			3	4		5
s.	Good professional contacts and collegiality in the medical community		1	2			3	4		5
t.	Opportunities for your professional growth/advancement		1	2			3	4		5
u.	Your investment in your practice (patient base, office, equipment, etc.)		1	2			3	4		5
v.	Good financial package		1	2			3	4		5
w.	Reasonable workload		1	2			3	4		5

25. Have you ever seriously considered moving and practicing in a different location?

1 = Yes

2 = No [IF NO, GO TO Q28, BELOW]

26. IF YES: What was the main reason that you considered leaving?

27. IF YES: What was the main reason that you decided to stay?

Availability and Quality of Health Care in [TOWN]

28. How would you rate the overall availability of health care in this community?

Poor	Fair	Good	Very Good	Excellent
1	2	3	4	5

31. How would you rate the overall quality of
health care in this community?

Poor	Fair	Good	Very Good	Excellent
1	2	3	4	5

29. In your opinion, how has the availability of health care services in this community changed over the past 5 years?

Declined a Lot	Declined a Little	No Change	Improved a Little	Improved a Lot
1	2	3	4	5

32. In your opinion, how has the quality of health care services in this community changed over the past 5 years?

Declined a Lot	Declined a Little	No Change	Improved a Little	Improved a Lot
1	2	3	4	5

30. In your opinion, are the changes in the availability of health care in this community
due to any of the following reasons?

33. In your opinion, are the changes in the
quality of health care in this community
due to any of the following reasons?

Yes

No

Don’t Know

Yes

No

Don’t Know

a.

Changes in health care facilities or equipment

1

2

3

a.

Changes in health care facilities or equipment

1

2

3

b.

Changes in health care professionals

1

2

3

b.

Changes in health care professionals

1

2

3

c.

Changes in health facility administration/ownership

1

2

3

c.

Changes in health facility administration/ownership

1

2

3

d.

Changes in government policies/programs

1

2

3

d.

Changes in government policies/programs

1

2

3

e.

Changes in the health insurance industry

1

2

3

e.

Changes in the health insurance industry

1

2

3

f.

Changes in the local economy or business community

1

2

3

f.

Changes in the local economy or business community

1

2

3

Recruitment and Retention of Other Providers

34. In the past 5 years, have you ever been involved in the recruitment of other health care professionals to your town?

1 =Yes

2 = No

35. In the past 5 years, have you ever been involved in an organized effort to encourage other local health care professionals to stay in your town?

1 =Yes

2 = No

36. In general, what would you say is the most important factor in successfully recruiting or retaining health care providers in [TOWN]?

37. In general, what would you say is the greatest difficulty in recruiting or retaining health care providers in [TOWN]?

Community Involvement
38. How much have you been involved in volunteer activities in this community that are related to health care or promoting healthy lifestyles? (E.g., speaking to local groups on health issues, helping address a local health problem, participating in a community health fair, etc.) 1 = Not at all 2 = Some 3 = A Lot	39. How much have you been involved in other volunteer activities in this community that are not related to health? (E.g., school, charity, sports activities, etc.) 1 = Not at all 2 = Some 3 = A Lot
40. Do you currently hold a local government leadership position in this community? 1 = Yes 2 = No	41. Do you currently hold a leadership position in a civic organization in this community? 1 = Yes 2 = No
42. How many local organizations or associations do you belong to in this community? (E.g., churches, service or sports clubs, school or business organizations, etc.) 0 = None 1 = One or two 2 = Three to five 3 = Six to ten 4 = More than ten	43. How easy is it for someone to get involved in community activities in this town? 1 = Very easy 2 = Somewhat easy 3 = Unsure 4 = Somewhat difficult 5 = Very difficult

Future Outlook
44. What are your professional plans for the next 5 years? 1 = Continue to practice in this community 2 = Move practice to another location 3 = Change career path in this community 4 = Change career path in another location 5 = Retire 6 = Other: _______________________________	45. If Q44 is 2, 3, or 4, please explain why.

Demographic Information
46. Your Gender: 1 = Male 2 = Female	47. Your current marital status: 1 = Married or living as married 2 = Divorced or separated 3 = Widowed 4 = Single never married
48. Your current age: _____ _____
49. Your Ethnicity: 1 = Hispanic 2 = Not Hispanic	50. Your Household (HH) Size: _______ Number in HH age 18 or older _______ Number in HH under 18 years old
51. Your race: (Circle all that apply) 1 = White 2 = Black or African American 3 = American Indian or Alaska Native 4 = Asian 5 = Native Hawaiian or Other Pacific Islander 6 = Other: ____________________________	52. Your household income in 2013: 1 = Less than $25,000 2 = From $25,000 up to $50,000 3 = From $50,000 up to $75,000 4 = From $75,000 up to $100,000 5 = From $100,000 up to $150,000 6 = $150,000 or more
53. Please record any other comments you would like to make regarding your experience as a health care provider in this community.

Thank you very much. Iowa State University and the USDA Economic Research Service greatly appreciate your cooperation and assistance. Please return your completed survey in the envelope provided.

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