Screener

Form Approved

OMB No. 0920-1027

Expiration Date: 08/31/2020

Public reporting burden of this collection of information is estimated to average 10 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-1027).

RECRUITMENT SCREENER

Internet Focus Groups for Exploratory Research with Primary Care Physicians (DVH)

2017

Hello. My name is __________ and I’m calling from ___________, an independent research firm.

You indicated that you are interested in participating in an internet focus group. We have an upcoming group to discuss your practices and opinions regarding screening guidelines. The sponsor of this group is the Centers for Disease Control and Prevention.

CDC is not interested in any personal details. We will be asking you a few questions to ensure we are recruiting a mix of people; but this information will not be shared with anyone.

RECORD GENDER:

Female	
Male	

What is your medical specialty? [READ LIST]

Family Physician	
General Internist	
General Practitioner Hospitalist	
Med-Peds (Combined Internal Medicine & Pediatrics)	
Other (Please Specify)	

Do you have a subspecialty? [If yes] What is it? [RECORD ON LINE BELOW:

Yes	
No	

4. What year did you complete medical school? ________

5. What was the name of your medical school? ____________________

6. What year did you complete your residency? ___________________

7. Is your primary responsibility direct patient care?

Yes	
No	

8. On average, how many hours per week do you spend in direct patient care? _________

9. Do you work or are you affiliated with any of the following?

State or local government agency such as Public Health Department	
Federal government agency, such as the Veterans Administration	
Academic Institution	
Private Corporation such as Pharmaceutical Companies, Research Lab	

10. Which best describes your practice setting?

Solo practice	
Single specialty group practice	
Multi-specialty group practice	
Staff Model Health Maintenance Organization or HMO	
Other model HMO, Managed Care Organization	
Network managed care systems such as PPOs	
Mixed model practice	
Hospital-based practice
Locum Tenens or temporary physician employment	
Practice seeing patients in a Hospital, Rehab or Nursing home	
Other: SPECIFY	

11. How many times within the past 6 months have you participated in a focus group or one-on-one interviews related to your professional expertise? [DON’T READ RESPONSE CATEGORY]

None	
1 or more	

INVITATION

Thank you for answering all of my questions. We would like to invite you to participate in a discussion with other primary care physicians. The purpose of this discussion is to discuss screening guidelines and how they are used in everyday practice. Please note we are advising all focus group participants to use a landline and have a reliable internet connection. The discussion will last approximately 90 minutes.

If you have any questions, please call the physician recruiting coordinator for this research at

1-866-386-6163 extension 499. If you have any questions specifically about the research please contact Cynthia Jorgensen DrPH, CDC Principal Investigator at (404) 718-8534 or cxj4@cdc.gov.

SEPARATE THIS CONTACT SHEET FROM THE RESET OF THE SCREENER

AND SHRED AT THE END OF THE STUDY