Form 1 Appendix A: Individual Respondent Characteristics Survey

Appendix A – Individual Respondent Characteristics

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

Diagnostic Safety Capacity Building – Calibration Resource

Please complete the following information about yourself. This document is completed at the time of recruitment/interview.

Individual Respondent Characteristics Survey

Characteristic	Response Option*
Sex	Male Female
Race	Check all that apply: White Black or African American American Indian or Alaska Native Asian Other: ______________________
Ethnicity	Hispanic or Latino Not Hispanic or Latino
Age in years
Professional Background	Physician (MD/DO) Physician Assistant Nurse Practitioner
Specialty and/or board certification(s)
Number of years in practice (since licensure)
Location	City, State: ___________________________
Practice Setting(s)	Office-based practice Primary Care Specialty Care FQHC Multispecialty Urgent Care Center Emergency Room Hospital Other: ____________________________
Organization type	 Academic medical center  Other not-for-profit  For-profit
Do you hold an academic appointment or affiliation?	Yes No
Are you involved in training learners in your discipline (e.g., medical students, interns, residents, and/or fellows)?	Yes No
*Each characteristic must include an option for did not respond/did not provide an answer

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