Attachment I1: Approved HC Facility Interview Questionnaire
[VARIABLE NAME] [C=Character or N=Numeric]
Form Approved
OMB No. 0920-0234
Notice
–
CDC estimates the average public reporting burden for this
collection of information as 45 minutes per response, including the
time for reviewing instructions, searching existing data/information
sources, gathering and maintaining the data/information 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 Information
Collection Review Office, 1600 Clifton Road, MS D-74, Atlanta, GA
30333; ATTN: PRA (0920-0234).
Assurance
of confidentiality –
We take your privacy very seriously. All information that relates
to or describes identifiable characteristics of individuals, a
practice, or an establishment will be used only for statistical
purposes. NCHS staff, contractors, and agents will not disclose or
release responses in identifiable form without the consent of the
individual or establishment in accordance with section 308(d) of the
Public Health Service Act (42 U.S.C. 242m(d)) and the Confidential
Information Protection and Statistical Efficiency Act (Title III of
the Foundations for Evidence-Based Policymaking Act of 2018 (Pub. L.
No. 115-435, 132 Stat. 5529 § 302)). In accordance with
CIPSEA, every NCHS employee, contractor, and agent has taken an oath
and is subject to a jail term of up to five years, a fine of up to
$250,000, or both if he or she willfully discloses ANY identifiable
information about you.
Script: Hello, my name is _____________, calling on behalf of the CDC’s National Center for Health Statistics regarding their study of health centers, as part of the National Ambulatory Medical Care Survey, or NAMCS. We are in the process of confirming and updating our contact information. Can I ask you a few questions about your center?
Initial Confirmation and Telephone Screen Call |
Can you please tell me if the following information is correct?
Health center name: [HC_NAME_CHK] [N]
Health center director: (Mr./Ms./Miss/Mrs./Dr.) [HC_DIR_SALUTE] [C]
Email Address: [HC_EMAIL_CHK] [N]
Address: [HC_ADDRESS_CHK] [N]
City: [HC_CITY_CHK] [N]
State: [HC_STATE_CHK] [N]
ZIP code: [HC_ZIP_CHK] [N]
Telephone number: [HC_PHONE_CHK] [N] Extension: [HC_PHONE_EXT_CHK] [N]
CONTINUE WITH Q2
Which of the following best describes your center? [HCTYPE] [N]
Federally Qualified Health Center (330 grantee) CONTINUE WITH Q3
Federally Qualified Health Center Look-Alike SKIP TO Q5
Urban Indian (437) Health Center READ SCRIPT BELOW AND CONCLUDE INTERVIEW
Other (Please Specify) SKIP TO Q4
If informant selects “URBAN INDIAN HEALTH CENTER” READ:
Script: At this time, we are only interviewing Federally Qualified Health Centers (FQHCs) and FQHC Look-Alikes. Thank you for your time.
END INTERVIEW.
Can your center also be classified as a: [FQHCTYPE] [N]
Migrant Health Center (MHC)
Health Care for the Homeless (HCH)
Public Housing Primary Care (PHPC) Grant Program
None of the above
SKIP TO Q5
Other – please Specify: ______________ [HCTYPEOTH] [C] READ SCRIPT BELOW AND CONCLUDE INTERVIEW
Script: At this time, we are only interviewing Federally Qualified Health Centers (FQHCs) and FQHC Look-Alikes, I need to confirm your health center’s eligibility and get back to you. Thank you for your time.
END INTERVIEW.
Are you the official who can agree to participate in NAMCS on behalf of the (INSERT HEALTH CENTER NAME)? [CONF_HCOFFIC] [N]
Can you identify an official who can agree to participate in NAMCS on behalf of the [INSERT HEALTH CENTER NAME]? This official could be the CEO, Director of Quality Control/Assurance, Health Information Management (HIM) Director, Research Director or someone else. May I have this person’s name, title, and contact information?
Salutation/Name: (Mr./Ms./Miss/Mrs./Dr.) [HC_DIR_SALUTE2] [C]
[HC_DIR_FIRST2] [C] [HC_DIR_LAST2] [C]
Title: [HC_DIR_TITLE2] [C]
Telephone number: [HC_DIR_PHONE2] [C] Extension: [HC_DIR_PHONE_EXT2] [C]
Email Address: [HC_DIR_EMAIL2] [C]
Address: [HC_DIR_ADDRESS2 [C]
City: [HC_DIR_CITY2] [C]
State: [HC_DIR_STATE2] [C]
ZIP Code: [HC_DIR_ZIP2] [C]
Continue with Q7
Can you please confirm if [INSERT HEALTH CENTER NAME] received an information packet and invitation to participate in NAMCS? [CEN_INFOPAK] [N]
Yes Continue with Q8
No Skip to Q9
Was this given to the [INSERT TITLE FROM Q6]? [DIR_INFOPAK] [N]
Yes
No
Continue with Q9
Can you please transfer me to [INSERT NAME FROM Q6 or Q12? [TRANSFER] [N]
Yes RECORD TRANSFER DATE/TIME AND SKIP TO Q11
No CONTINUE WITH Q10
Record transfer date and time:
_____/______/_____ [TRANSFER_DATE] [C]
Day / Month /Year
Time: _____:_____ _____A.M. _____P.M. _____ Time Zone [TRANSFER_TIME] [C]
What is a good time to call back and speak with the [INSERT TITLE FROM Q6 or Q12]?
Schedule a date and time to call back within 3 days and enter call back information.
Thank informant for their time and repeat the date and time of the next scheduled contact.
_____/______/_____ [CALLBACK1_DATE] [C]
Day / Month/Year
Time: _____:_____ _____A.M. _____P.M. _____Time Zone [CALLBACK1_TIME] [C]
Conclude interview and call back at specified time.
CONTINUE WITH Q11 DURING CALL BACK.
TRANSFER TO OFFICIAL:
Script: Hello, my name is _____________, calling on behalf of the Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS) regarding the National Ambulatory Medical Care Survey, known as NAMCS. The NCHS selected (INSERT HEALTH CENTER NAME) as part of a nationally representative sample to participate in NAMCS. You were identified as someone who could authorize participation in NAMCS. If I could have a few minutes of your time, I’d like to ask you a few questions about your health center.
As the [INSERT TITLE FROM Q6 or Q12], are you authorized to agree to participate on behalf of [INSERT HEALTH CENTER NAME]? [AUTH_RESPONDENT] [N]
Yes Skip to Q13 AND READ PRIOR INTRODUCTION SCRIPT
No Continue with Q12
Who is the best person who can authorize participation in the survey?
Name: (Mr./Ms./Miss/Mrs./Dr.) [AUTH_SALUTE] [C] [AUTH_FIRST] [C] [AUTH_LAST] [C]
Job title: [AUTH_TITLE] [C]
Telephone Number: [AUTH_PHONE] [C] Extension: [AUTH_EXT] [C]
E-mail: [AUTH_EMAIL] [C]
Address: [auth_address] [c]
City: [AUTH_CITY] [C]
State: [AUTH_STATE] [C]
zip code: [AUTH_ZIP] [C]
Go back to Q9
INTRODUCTION (For A New authorizing official confirmed in q5 or Q11)
Script: The NCHS selected (INSERT HEALTH CENTER NAME) as part of a nationally representative sample to participate in NAMCS. Your participation in the survey is voluntary and will help health care providers and professionals plan for more effective health services, improve medical and health education, and assist the public health community in understanding the patterns of diseases and health conditions. If you choose to participate in NAMCS, the NCHS will offer your health center a set-up fee of up to $10,000 to help transmit patient level electronic health record (EHR) data such as medical records and visits for the calendar year.
Interview with Health Center Official |
Did you receive the NAMCS information packet? [AUTH_INFOPAK] [N]
Yes Skip to Q18
No Script: I apologize and will ensure the information is sent to you right away. Continue with Q14
Can I email you the information while you remain on the phone to confirm you received it? [AUTH_INFO_LETTER] [N]
Yes CONTINUE WITH Q15 TO CAPTURE EMAIL AND EMAIL LETTER
No SKIP TO Q16 TO CONFIRM MAILING ADDRESS TO BE USED TO SEND A NEW LETTER
Script: If you’d like, I can read the letter to you over the phone.
CONTINUE WITH Q16
Programming note: Autofill contact information.
Could you please confirm the following contact information? [AUTH_CONFIRM] [N]
Confirm authorized official email from Q6 or Q12 and mailing address to mail new recruitment package.
Name: (Mr./Ms./Miss/Mrs./Dr.) ___(FILL FROM Q6 OR Q12 OR Q1)___________
Health Center name: ____________(FILL FROM Q6 OR Q12 OR Q1)____________
Address: ____________________(FILL FROM Q6 OR Q12 OR Q1)_____________
City, State and ZIP code: ________(FILL FROM Q6 OR Q12 OR Q1)____________
E-mail: ____________________(FILL FROM Q6 OR Q12 OR Q1)______________
CONTINUE WITH Q17 TO schedule another time to call back within a week, if the person is unable or unwilling to continue at this time.
What would be a good time to call back?
Record date and time of next scheduled telephone call:
_____/______/_____ [CALLBACK2_DATE] [C]
Day / Month /Year
Time: _____:_____ _____A.M. _____P.M. _____Time Zone [CALLBACK2_TIME] [C]
Conclude interview and call back at specified time.
DURING SCHEDULED CALL BACK, GO BACK TO Q13.
OTHERWISE, CONTINUE WITH Q18.
Do you have any questions about the information you received or concerns about what we have discussed so far? [AUTH_QUES] [N]
Yes Continue with Q19
No Skip to Q20
Record major topics below. Use materials to try to address each one.
___________________________________ [AUTHTOPIC_1] [C]
___________________________________ [AUTHTOPIC_2] [C]
___________________________________ [AUTHTOPIC_3] [C]
___________________________________ [AUTHTOPIC_4] [C]
___________________________________ [AUTHTOPIC_5] [C]
CONTINUE WITH Q20
Can we count on your health center’s participation in NAMCS? [HCPART] [N]
Yes Skip to Q26
Need more information CONTINUE WITH Q21
No, health center official declines to participate. skip to q23
Record major topics below. Use materials to try to address each one.
___________________________________ [HCTOPIC_1] [C]
___________________________________ [HCTOPIC_2] [C]
___________________________________ [HCTOPIC_3] [C]
___________________________________ [HCTOPIC_4] [C]
___________________________________ [HCTOPIC_5] [C]
CONTINUE WITH Q22
Do you need more information or time to decide on your health center’s participation in NAMCS? [MORETIME] [N]
Yes DOCUMENT CALL BACK DATE/TIME
No GO BACK TO Q20
Record date and time to call back.
_____/______/_____ [CALLBACK3_DATE] [C]
Day / Month/Year
Time: _____:_____ _____A.M. _____P.M. _____Time Zone [CALLBACK3_TIME] [C]
Script: We will reach back out on [repeat date and time of scheduled call back]. Thank you for your time.
CONCLUDE INTERVIEW.
DURING CALL BACK, GO BACK TO Q20
Please tell me why your health center does not want to participate.
RECORD RESPONSE TO BE CODED LATER: ___________________ [REFUSE_REPONSE] C]
Thank the official for their time and end interview.
CONTINUE WITH Q24
DO NOT READ THESE RESPONSES OUT LOUD; Instead; check the option that best captures the official’s reason for refusal. [WHY_REF] [N]
Confidentiality concerns
The health center’s financial situation does not permit it to dedicate time to this effort
The health center has too many other priorities at this time
Other CONTINUE WITH Q25
Other – please specify: ____________________________________ [REFUSE_OTH] [C]
CONCLUDE interview.
I
have a few additional questions that I need to ask about your health
center. Can you please provide the name, title and contact
information for a primary
contact,
the person
who will be responsible for transmitting data
to the National Ambulatory Medical Care Survey?
Name: (Mr./Ms./Miss/Mrs./Dr.) [TRANSMIT_C_SALUTE] [C] [TRANSMIT_C_FIRST] [C] [TRANSMIT_C_LAST] [C]
Job title: [TRANSMIT_C_TITLE] [C]
Telephone Number: [TRANSMIT_C_PHONE] [C] Extension: [TRANSMIT_C_EXT] [C]
E-mail: [TRANSMIT_C_EMAIL] [C]
CONTINUE WITH Q27
Is this a good time to complete the Facility Interview; if not what would be a good time to call back?
CONTINUE WITH Q28 if the participant agrees. If it is not a good time schedule a date and time to call back within a week, if feasible, to complete the facility interview and enter below. Thank interviewee for their time and repeat the date and time of the next scheduled contact.
_____ /______/_____ [CALLBACK4_DATE] [C]
Day / Month /Year
Time: _____:_____ _____A.M. _____P.M. _____Time Zone [CALLBACK4_TIME] [C]
END SCREENER. Continue with Q28 during the follow-up call.
Script: Hello, my name is _____________, calling on behalf of the Centers for Disease Control and Prevention (CDC) National Center for Health Statistics (NCHS) National Ambulatory Medical Care Survey, known as NAMCS. We recently spoke with [FILL IN NAME OF CENTER OFFICIAL], and [HE/SHE] identified you as our primary point of contact for the survey.
The Facility Interview Questionnaire will take approximately 45 minutes to complete with me over the phone. Is this a good time? [BEGIN_FACINT] [N]
Yes SKIP TO Q30
No CONTINUE WITH Q29 TO SET CALLBACK APPOINTMENT
What would be a good date/time to call back?
Record date and time of next scheduled telephone call:
_____/______/_____ [TRANSMIT_C_DATE] [C]
Day / Month/Year
Time: _____:_____ _____A.M. _____P.M. _____Time Zone [TRANSMIT_C_TIME] [C]
RETURN TO Q28 DURING CALL BACK.
Health Center Primary Contact Interview |
Is this health center a subsidiary of a larger company or network? [HC_NETWORK] [N]
Yes CONTINUE WITH Q31
No SKIP TO Q33
Don’t know SKIP TO Q32
What is the name of the larger company or network? [NETWORK_NAME] [C]
SKIP TO Q33
Who is the best person to contact for this information?
Name: (Mr./Ms./Miss/Mrs./Dr.) [NETWORK_SALUTE] [C] [NETWORK_FIRST] [C] [NETWORK_LAST] [C]
Job title: [NETWORK_TITLE] [C]
Telephone Number: [NETWORK_ PHONE] [C] Extension: [NETWORK_EXT] [C]
E-mail: [NETWORK_EMAIL] [C]
Continue with Q33
Are other health centers covered under your state license? [HC_LICENSE] [N]
Yes CONTINUE WITH Q34
No SKIP TO Q36
Don’t know SKIP TO Q35
What are the name(s) of the health center(s)?
[HC_LICENSENAM1] [C] _________________________________
[HC_LICENSENAM2] [C] _________________________________
[HC_LICENSENAM3] [C] _________________________________
SKIP TO Q36
Who is the best person to contact for this information?
Name: (Mr./Ms./Miss/Mrs./Dr.) [LIC_SALUTE] [C] [LIC_FIRST] [C] [LIC_LAST] [C]
Job title: [LIC_TITLE] [C]
Telephone Number: [LIC_PHONE] [C] Extension: [LIC_EXT] [C]
E-mail: [LIC_EMAIL] [C]
Continue with Q36
When this health center reports data to the governing bodies is the information solely for this health center or are other health centers included in the data transmission? [REPDATOTH] [N]
Solely for this health center Skip to Q38
Combined with one or more other health centers Continue with Q37
What are the name(s) of the other health centers?
___________________________________________ [REPDATOTH_NAM1] [C]
___________________________________________ [REPDATOTH_NAM2] [C]
___________________________________________ [REPDATOTH_NAM3] [C]
Continue with Q38
Part 2. General Questions
Was this health center open for the full calendar year (FILL PREVIOUS CALENDAR YEAR)? [HCOPEN_PREV] [N]
Yes SKIP TO Q40
No CONTINUE WITH Q39
Never open in (FILL PREVIOUS CALENDAR YEAR) SKIP TO Q40
Please provide the dates the health center was closed in (FILL PREVIOUS CALENDAR YEAR): ______________________________________________
Period 1: [startmth1] [startday1] [endmth1] [ENDDAY1] [n]
Period 2: [STARTMTH2] [STARTDAY2] [ENDMTH2] [ENDDAY2] [n]
Period 3: [startmth3] [startday3] [endmth3] [ENDDAY3] [n]
CONTINUE WITH Q40
Do you anticipate any significant changes in your visit volume in (FILL CURRENT CALENDAR YEAR)? [VISCHG_CURR] [N]
Yes Continue with Q41
No SKIP TO Q42
Please explain: _______________ [WHY_VISCHG_CURR] [C]
Continue with Q42
During its last normal year, approximately how many office visit encounters did this health center have?
Only include the visits to the sampled health center.
Note: if participant asks for clarification, say: an example of a normal year is 2019, prior to COVID-19.
Enter number of visits: ______________________________________ [AVG_TOTVIS] [N]
continue with Q43
Approximately how many office visit encounters do you estimate this health center will have in (FILL CURRENT CALENDAR YEAR)?
Only include the visits to the sampled health center.
Enter estimated visits: ____________________________________ [EST_TOTVIS_CURR] [N]
continue with Q44
Please provide the actual counts or your best estimates for the total number of health center visits during calendar year (FILL PREVIOUS CALENDAR YEAR) for each quarter if possible, and for the year overall.
|
Annual |
Quarter 1 |
Quarter 2 |
Quarter 3 |
Quarter 4 |
All visits made to health center: |
[TOTVIS] [C] |
[TOTVISQ1] [C] |
[TOTVISQ2] [C] |
[TOTVISQ3] [C] |
[TOTVISQ4] [C] |
Continue with Q45
Electronic Health Records (EHR)
Are you able to electronically output patient level data from your electronic health record (EHR) system? [EHR_OUPUT] [N]
Yes
No
Don’t know
Continue with Q46
Is your health center’s EHR system compatible with the Health Level 7 (HL7) Clinical Document Architecture (CDA®) R2 Implementation Guide (IG): National Health Care Surveys (NHCS) Release 1, Draft Standard for Trial Use (DSTU) 1.2 – U.S. Realm? [EHR_COMPAT] [N]
Yes SKIP TO Q48
No Continue with Q47
Don’t know Continue with Q47
Do you need assistance setting up your EHR system to ensure that it is compatible with the 1.2 version of the HL7 CDA® R2 IG: NHCS Release 1, DSTU 1.2 – U.S. Realm? [EHR_SETUP] [N]
Yes
No
Don’t know
CONTINUE WITH Q48
Will the data you provide include electronic health records from your health center only?
[EHR_HCONLY] [N]
Yes SKIP TO Q52
No CONTINUE WITH Q49
Don’t know SKIP TO Q52
Is it possible to identify the records from your health center separate from the other health centers that report with you? [EHR_HCID] [N]
Yes
No
Don’t know
CONTINUE WITH Q50
Data Transfer
What are the name(s) of the other health centers included?
_______________________________________________________
[EHR_OTHNAM1] [C]
[EHR_OTHNAM2] [C]
[EHR_OTHNAM3] [C]
Continue with Q51
How can we make that distinction? ________________ [EHR_DIST] [C]
Continue with Q52
Who is the IT/data contact for transmitting your health center’s data and what is their contact information?
Name: (Mr./Ms./Miss/Mrs./Dr.) [IT _SALUTE] [C] [IT _FIRST] [C] [IT _LAST] [C]
Job title: [IT _TITLE] [C]
Telephone Number: [IT _PHONE] [C] Extension: [IT _EXT] [C]
E-mail: [IT _EMAIL] [C]
Continue with Q53
COVID-19 Information |
Script: Now I would like to ask you a few questions about the coronavirus disease (COVID-19) and the impact it had on operations in your Center and on your staff.
For questions 53 and 54: During the past THREE months, how often did your center experience shortages of any of the following personal protective equipment due to the onset of the coronavirus disease (COVID-19) pandemic?
Check only one box per piece of equipment.
N95 respirators or other approved facemasks [COVID_N95_RESP] [N]
CONTINUE WITH Q54
Eye protection, isolation gowns, or gloves [COVID_EYE] [N]
Never
Some of the time
Most of the time
All of the time
Don’t know
During the past THREE months, did your center have the ability to test patients for coronavirus disease (COVID-19) infection? [COVID_TEST] [N]
Check only one box.
Yes Continue with Q56
No SKIP TO Q57
Not applicable – did not need to do any COVID-19 testing Skip to Q58
Don’t know SKIP TO Q57
During the past THREE months, how often did your center experience shortages of coronavirus disease (COVID-19) tests for any patients who needed testing? [COVID_SHORT] [N]
Check only one box.
Never
Some of the time
Most of the time
All of the time
Don’t know
SKIP TO Q58
During the past THREE months how often did your center have a location where patients could be referred to for coronavirus disease (COVID-19) testing? [COVID_REFER] [N]
Check only one box.
Never
Some of the time
Most of the time
All of the time
Don’t know
CONTINUE WITH Q58
During the past THREE months, did your center need to turn away or refer elsewhere any patients with confirmed or presumptive positive coronavirus disease (COVID-19) infection? [COVID_AWAY] [N]
Check only one box.
No, COVID-19 patients were not turned away or referred elsewhere
Yes, some COVID-19 patients were turned away or referred elsewhere
Yes, most COVID-19 patients were turned away or referred elsewhere
Yes, all COVID-19 patients were turned away or referred elsewhere
Not applicable – the center did not have any COVID-19 patients
Don’t know
CONTINUE WITH Q59
For questions 59 – 64: During the past THREE months, did any of the following clinical care providers in your center test positive for coronavirus disease (COVID-19) infection?
Check only one box per provider.
Physicians [COVID_PROV1] [N]
Yes
No
Not applicable – did not have such provider type onsite
Don’t know
CONTINUE WITH Q60
Physician assistants [COVID_PROV2] [N]
Yes
No
Not applicable – did not have such provider type onsite
Don’t know
CONTINUE
WITH Q61
Nurse practitioners [COVID_PROV3] [N]
Yes
No
Not applicable – did not have such provider type onsite
Don’t know
CONTINUE WITH Q62
Certified nurse-midwives [COVID_PROV4] [N]
Yes
No
Not applicable – did not have such provider type onsite
Don’t know
CONTINUE WITH Q63
Registered nurses/licensed practical nurses [COVID_PROV5] [N]
Yes
No
Not applicable – did not have such provider type onsite
Don’t know
CONTINUE WITH Q64
Other clinical care providers [COVID_PROV6] [N]
Yes CONTINUE WITH Q65
No SKIP TO Q66
Not applicable – did not have such provider type onsite SKIP TO Q66
Don’t know SKIP TO Q66
Please specify the other clinical care providers in your center that tested positive for coronavirus disease (COVID-19) infection: __________________________
[COVID_PROV_OTH1] [C]
[COVID_PROV_OTH2] [C]
[COVID_PROV_OTH3] [C]
CONTINUE WITH Q66
During January and February 2020, was your center using telemedicine or telehealth technologies (for example, audio with video, web videoconference) to assess, diagnose, monitor, or treat patients? [TELEMED] [N]
Yes Continue with Q67
No SKIP TO Q69
Don’t know SKIP TO Q71
After February 2020, did your center’s use of telemedicine or telehealth technologies to conduct patient visits increase? [TELEMED_INC] [N]
Yes Continue with Q68
No Skip to Q71
Don’t know Skip to Q71
After February 2020, how much has your center’s use of telemedicine or telehealth technologies to conduct patient visits increased? [TELEMED_INC_PER] [N]
Check only one box.
Less than 25%
25% to 49%
50% to 74%
75% or more
Don’t know
Skip to Q71
After February 2020, has your center started using telemedicine or telehealth technologies? [TELEMED_START] [N]
Yes CONTINUE WITH Q70
No skip to Q71
Don’t know skip to Q71
Since your center started using these technologies, how many of your patient visits have been conducted using telemedicine or telehealth technologies? [TELEMED_START_PER] [N]
Check only one box.
Less than 25%
25% to 49%
50% to 74%
75% or more
Don’t know
continue with Q71
Payment Information |
Script: This next question relates to reimbursement to your health center for participating in the survey. Your health center will receive a onetime set-up fee of up to $10,000 for the electronic data transmission required by NAMCS participants.
Can
you tell
me
to
whom
the
checks
should
be
sent?
[PAYINFO_SEND]
[N]
Yes CONTINUE WITH Q72
No SKIP TO Q73
Enter information and then thank official for their time and end interview.
Payee: (Mr./Ms./Miss/Mrs./Dr.) [PAY1_SALUTE] [C] [PAY1_FIRST] [C] [PAY1_LAST] [C]
Attn: [PAY1_ATTN] [C]
Job Title: [PAY1_TITLE] [C]
Address: [PAY1_STREET] [C]
City/State/ZIP Code: [PAY1_CITY] [C] / [PAY1_STATE] [C] / [PAY1_ZIP] [C]
Telephone Number: [PAY1_PHONE] [C] Extension: [PAY1_EXT] [C]
E-mail: [PAY1_EMAIL] [C]
Script: Thank you for your time and your contribution to the National Ambulatory Medical Care Survey.
END INTERVIEW.
Is there someone else that I should speak with about getting this information?
Name: (Mr./Ms./Miss/Mrs./Dr.) [PAYINFO_SALUTE] [C] [PAYINFO_FIRST] [C] [PAYINFO_LAST] [C]
Job title: [PAYINFO_TITLE] [C]
Telephone Number: [PAYINFO_PHONE] [C] Extension: [PAYINFO_EXT] [C]
E-mail: [PAYINFO_EMAIL] [C]
Script: Thank you for your time and your contribution to the National Ambulatory Medical Care Survey.
END INTERVIEW.
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Monica Wolford |
File Modified | 0000-00-00 |
File Created | 2022-10-24 |