Form 1 Appendix A

Appendix A – Practice Descriptive Characteristics

Form Approved
OMB No. xxxx-xxxx
Exp. Date xx/xx/20

Diagnostic Safety Capacity Building – Patient and Family Resource

Please complete the following information about your practice:

General Information About Your Practice

Practice Name
Location (City, State)
Select one:	Urban Inner City Rural Suburban Other (Specify)
Contact Person
Medical Director
Number of	Physicians	__________
	Nurse Practitioners	__________
	Nurses	__________
	Medical Assistants	__________
	Pharmacists	__________
	Social Workers	__________
	Case Managers Other Practice Staff	__________ __________
	Other (specify)	__________
Total Number of Patients Served by Practice
Payer Mix (Indicate % of Patients)	Self-Pay Medicare Medicaid Private Insurance Uninsured Other	_________% _________% _________% _________% _________% _________%
Race (indicate % of patients)	White Black or African American American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander	_________% _________% _________% _________% _________%
Ethnicity (indicate % of patients)	Hispanic or Latino Not Hispanic or Latino	_________% _________%

Information about Patient Safety and Quality Improvement Activities of the Practice

	Yes	No
Does your practice routinely conduct a patient safety culture survey?	☐ Please specify which survey you use: _____________ Date of the last survey ________	☐
Is your practice part of a larger healthcare system?	☐ Please indicate which health system you are affiliated with: ___________________	☐
Is your practice currently working on any other practice improvement strategies?	☐	☐
Does your practice have or use the services of a practice facilitator?	☐	☐

This survey is authorized under 42 U.S.C. 299a. The confidentiality of your responses to this survey is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)].  Information that could identify you will not be disclosed unless you have consented to that disclosure. Public reporting burden for this collection of information is estimated to average 60 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, 5600 Fishers Lane, Room #07W42, Rockville, MD 20857.