ࡱ> tvu @ Mbjbj00 ,\RRL>>>8vt47*X@@@$7!6666666$!9Rs;6G&G&G&6@@Y7o,o,o,G&<8@@6o,G&6o,o,r"5T"6@ PQ|N>'v5r64o7075+<(+<"6+<"6PK"1#o,#Y$K"K"K"66dZS,Z Instrument Title: Demographic and Practice Characteristics Questionnaire Inclusion Criteria: Is your practice in Family Medicine, Internal Medicine, Pediatrics or Womens Health? Yes:  FORMCHECKBOX __________ No:  FORMCHECKBOX ______________ Do you estimate that 25% or greater of your patient panel is foreign-born? Yes:  FORMCHECKBOX _________________________No:  FORMCHECKBOX _______________ Have you been practicing at your site for at least 1 year? Yes: FORMCHECKBOX  ________________________No:  FORMCHECKBOX _______________ Have you been practicing as a clinician, including residency, for at least 3 years? Yes:  FORMCHECKBOX ________________________No:  FORMCHECKBOX ____________________ Are you able to speak, comprehend and read English? Yes:  FORMCHECKBOX _______________________ No:  FORMCHECKBOX _____________________ If you answered NO to any of the above questions, STOP. Please speak with a member of the Research staff immediately. Exclusion Criteria: Are you an employee of a Public Health Department?(exclusion) Yes: FORMCHECKBOX ________________ No: FORMCHECKBOX _____________ If you answered YES, STOP. Please speak with a member of the Research Staff immediately. Otherwise please continue onto the next page to fill out the questionnaire. We would like you to respond to the following questions. The questionnaire is meant to be anonymous although your responses to the demographic questions could possibly identify you. The questionnaire will not be linked to your name. You do not have to answer every question. What is your age?  FORMTEXT      __________________________(years) What is your gender? Male FORMCHECKBOX __________ Female  FORMCHECKBOX _____________ In what country were you born?  FORMTEXT      ____________________________ If you immigrated to the United States, at what age did you immigrate?  FORMTEXT      ________(years) Race (circle those that apply) Black or African American FORMCHECKBOX  White FORMCHECKBOX  American Indian or Alaskan Native FORMCHECKBOX  Asian FORMCHECKBOX  Native Hawaiian or Pacific Islander FORMCHECKBOX  If you circled Asian/ Pacific Islander, circle those that apply: Asian Indian FORMCHECKBOX  Chinese FORMCHECKBOX  Filipino FORMCHECKBOX  Japanese FORMCHECKBOX  Korean FORMCHECKBOX  Vietnamese FORMCHECKBOX  Native Hawaiian FORMCHECKBOX  Guamanian or Chamorro FORMCHECKBOX  Samoan FORMCHECKBOX  Other Asian (specify)  FORMCHECKBOX _________________ Other Pacific Islander (specify)  FORMCHECKBOX _________________ Are you Hispanic or Latino? Yes  FORMCHECKBOX __________ No  FORMCHECKBOX ___________ If you answered yes, please check one: Mexican  FORMCHECKBOX _________ Puerto Rican  FORMCHECKBOX ________ Cuban  FORMCHECKBOX __________ Other (specify)  FORMTEXT      ___________ What is your job title? MD (Medical Doctor) FORMCHECKBOX  DO (Doctor of Osteopathy)  FORMCHECKBOX  ARNP (Advanced Registered Nurse Practitioner) FORMCHECKBOX  PA (Physicians Assistant) FORMCHECKBOX  Nurse (specify RN, LPN, BSN)  FORMCHECKBOX ________________________ Pharmacist FORMCHECKBOX  Administrator  FORMCHECKBOX  Other: _ FORMTEXT      __________________________ For MDs only: In what area did you do your residency? Family Medicine FORMCHECKBOX  Internal Medicine FORMCHECKBOX  Pediatrics FORMCHECKBOX  Other:  FORMTEXT      _____________________________________ How many years have you performed in your current job title? (Include years of residency if applicable).  FORMTEXT      _______________________________________ How many years have you worked at your current site?  FORMTEXT      __________________ What is the approximate size of your patient panel? FORMTEXT       __________________ Type of practice Private Practice: Solo MD Private Practice: Group practice 1-4 doctors Private Practice: Group practice 5+ doctors community clinic or health center hospital based clinic Employee of HMO (such as Group Health or Kaiser) other: __________________________ Please estimate the percentage of time you spend in patient care: _ FORMTEXT      _________% Please estimate the percentage of your patient that is foreign born:  FORMTEXT      __________% Of your foreign born patients,estimate the percentage that are: Vietnamese:  FORMTEXT      ________________% Mexican:  FORMTEXT     ILMNPQefghY Z h i j  ¼}rgjhL'Uj\hL'UjhL'UjthL'UjhL'UjhL'Uh~nhL' hL'5\ heo5\ hL'CJhL'5>*\heo5>*\ heoCJ hcCJ h7CJheohL'CJheoheoCJheo>*OJQJ(LNPQefh T 6  o p ^ & F $&dPa$gd7$&dPa$gdc$&dPa$gdeo6GMM  $ % &   * + , H I W X Y > ? 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Seen? Number of PPDs given/ # positive/ # of patients being treated for LTBI/ on INH?cases seen in the last 2 years: FORMTEXT      ________________ Average number of PPD positive patients managed in a month:  FORMTEXT      ______________ Have you had any training specifically for TB?  FORMTEXT      ____________________ If yes, what was this training?  FORMTEXT      ____________________________ _________________________________________________________________ MDs only: In what country did you receive your medical training?  FORMTEXT      ___________________ MDs only: What specialty or sub-specialty training have you had?  FORMTEXT      ____________ Project Title: Primary Care Management of Latent and ActiveTuberculosis Among Immigrant Populations: A Study of Barriers and Facilitators Project Dates: 2003 - 2007 Method: Questionnaire Topic: LTBI, treatment adherence Target Audience: Health care providers who serve foreign-born populations Principal Investigator(s): Jenny Pang, MD1 ( HYPERLINK "mailto:jenny.pang@metrokc.gov" jenny.pang@metrokc.gov); J. Carey Jackson2 ( HYPERLINK "mailto:jackson.c@u.washington.edu" jackson.c@u.washington.edu); Nickolas DeLuca, PhD3 ( HYPERLINK "mailto:ncd4@cdc.gov" ncd4@cdc.gov) 1. Seattle & King County Public Health Department, Seattle, Washington; 2. University of Washington, Seattle, Washington; 3. Centers for Disease Control and Prevention, Atlanta, Georgia PAGE  PAGE 1 CCCCCCC,D.DBDDDFDPDRDDDDDDDD"F$F8F:F*B*phdd\LNPQefh T6op:+-@A53J - E a ? A ] }  0 _ w  2 y ! 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