We request your participation in an online survey to better understand the outcomes of the Health Resources and Services Administration (HRSA) funded Teaching Health Center (THC) program.
Participation in this survey is voluntary. The survey consists of two parts:
* Part One collects information about your current employment. Your responses to Part One will be shared with your residency program.
* Part Two collects information about your experiences with your residency program. Your responses to Part Two are confidential and will not be shared with your residency program.
Please Note: After you complete Part One you will submit "Done" and be directed to Part Two on a separate webpage.
The total amount of time you will spend on this survey is generally no more than 10-15 minutes. If results of this survey are reported in journals or at scientific meetings, the people who participated will not be named or identified.
Participation is voluntary and if you feel any discomfort answering the survey questions, you are free to skip any questions or stop taking the survey at any point. Taking part in this study will not benefit you directly; however the benefit to society will be a greater understanding of how
residency programs can better serve the nation by training doctors in the communities most in need of care. Please talk to the research team if you have questions, concerns, complaints, or think you have been harmed. You can contact the Principal Investigator, Dr. Marsha Regenstein, at 202- 994-8662. For questions regarding your rights as a participant in human research call the GWU Office of Human Research at 202-994-2715.
Your willingness to participate is implied if you proceed with completing this survey.
Public Burden Statement: 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. The OMB control number for this project is 0915-0376. Public reporting burden for this collection of information is estimated to average .33 hour per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10C-03I, Rockville, Maryland, 20857. OMB # 0915-0376 & Expiration Date 03/31/2017
Evaluation and Initial Assessment of HRSA Teaching Health Centers
Alumni Survey Part One OMB # 0915-0376 & Expiration date 03/31/2017
Alumni Survey Part One OMB # 0915-0376 & Expiration date 03/31/2017
Certification & Licensing
First Name Last Name Primary Email
Please provide your first and last name. This information is necessary for the Part One of this survey.
Are you currently board certified?
Yes No
Other (please specify)
If yes, what board certifications do you maintain? Please check all that apply and add any specialty certifications as appropriate.
Family Medicine - ABFM Family Medicine - AOA Internal Medicine - ABIM Internal Medicine - AOA Pediatrics - ABP Pediatrics - AOA OB/Gyn - ABOG OB/Gyn - AOA Psychiatry - ABPN Psychiatry - AOA General Dentistry - ABGP Pediatric Dentistry - ABPD
Do you currently hold an active medical or dental license?
Yes No
State: -- select state --
Additional State(s)
If yes, in what state(s) do you hold an active license?
Do you have an active National Provider Identifier (NPI) number?
Yes No
Don't Know/Prefer Not to Submit
If yes, please enter your NPI number.
Additional Training
Alumni Survey Part One OMB # 0915-0376 & Expiration date 03/31/2017
Are you currently in a training position, such as a residency or fellowship?
Yes, a medical or surgery sub-specialty fellowship Yes, an additional residency
No
Additional Training
Alumni Survey Part One OMB # 0915-0376 & Expiration date 03/31/2017
Please provide the specialty of the program:
Additional Training
Alumni Survey Part One OMB # 0915-0376 & Expiration date 03/31/2017
Have you completed any additional training, such as a residency or fellowship, since your primary residency program?
Yes No
If you have completed additional training, please provide the specialty of the program:
Employment
Alumni Survey Part One OMB # 0915-0376 & Expiration date 03/31/2017
Are you currently practicing clinical medicine or dentistry?
Yes, clinical medicine Yes, dentistry No
Practice Information
Alumni Survey Part One OMB # 0915-0376 & Expiration date 03/31/2017
Are you providing patient care full-time or part-time?
Full-time (at least 36 hours a week) Part-time (less than 36 hours a week)
The following questions gather information about your principal practice site where you practice clinically (i.e. provide patient care) - this may include seeing patients independently or with trainees, such as students or residents.
Principal Clinical Practice Site
Alumni Survey Part One OMB # 0915-0376 & Expiration date 03/31/2017
Name:
City/Town:
State: -- select state --
Country:
Please enter the following information for your PRINCIPAL practice site - this is the physical location where you spend most of your patient care time.
Yes No
Part of a Federally Qualified Health Center Located in a Rural Area
Located in an Underserved Area Part of a Patient-Centered Medical Home Part of an Accountable Care Organization
Part of a concierge or membership healthcare option
Please indicate "yes" or "no" if your principal practice site is:
Other (please specify)
What specialty do you primarily practice in your principal practice site? Choose one.
General Family Medicine General Internal Medicine General Pediatrics OB/Gyn
Psychiatry Geriatrics Dentistry
FTE % FTE = 100%; Each half day per week is considered 10%.
What percent of a full-time equivalent (FTE) are you working at your principal practice site?
Number of Patients Please select an integer.
How many patients do you typically see in this practice setting during a half day of practice?
Other (please specify)
Where do you generally see your patients in your principal practice? You may choose more than one option.
Outpatient Inpatient
Emergency Department
% of patient population that are racial/ethnic minorities Please select your best approximation. If none
select 0.
In your principal practice, what percent of your patient population are racial/ethnic minorities?
% of patient population on Medicaid Please select your best approximation. If none
select 0.
In your principal practice, what percent of your patient population are on Medicaid?
% of patient population who are uninsured Please select your best approximation. If none
select 0.
In your principal practice, what percent of your patient population are uninsured?
Additional Practice Sites
Alumni Survey Part One OMB # 0915-0376 & Expiration date 03/31/2017
Are you providing patient care at any other sites?
Yes No
Additional Practice Sites
Alumni Survey Part One OMB # 0915-0376 & Expiration date 03/31/2017
If yes, how many other sites?
1 2 3 4 or more
Additional Clinical Practice Sites
Alumni Survey Part One OMB # 0915-0376 & Expiration date 03/31/2017
Yes No
Part of a Federally Qualified Health Center Located in a Rural Area
Located in an Underserved Area Part of a Patient-Centered Medical Home Part of an Accountable Care Organization
Part of a concierge or membership healthcare option A high Medicaid site (at least 25% of the patients are on Medicaid)
A high uninsured site (at least 25% of the patients are uninsured)
Please indicate if at least one of your additional practice sites is:
Other (please specify)
Across your additional practice sites, what specialty do you primarily practice? You may select more than one option.
General Family Medicine General Internal Medicine General Pediatrics OB/Gyn
Psychiatry Geriatrics Dentistry
Other (please specify)
Where do you generally see your patients in your additional practice sites? You may choose more than one option.
Outpatient Inpatient
Emergency Department
Employment Non-Practicing
Alumni Survey Part One OMB # 0915-0376 & Expiration date 03/31/2017
If you are not practicing clinical medicine or dentistry, what are you currently doing?
Non-Patient Service Time
Alumni Survey Part One OMB # 0915-0376 & Expiration date 03/31/2017
Do you have time in your job reserved for non-patient care related activities (such as teaching, research or administration)?
Yes No
Non-Patient Service Time
Alumni Survey Part One OMB # 0915-0376 & Expiration date 03/31/2017
Teaching % of FTE Research % of FTE Administration % of FTE 1 FTE = 100%. Each half day per week is
considered 10%.
Other (Please specify area and FTE)
If yes, please indicate what percent of a full-time equivalent (FTE), regardless of location, you are working in each of the following areas:
Community Service
Alumni Survey Part One OMB # 0915-0376 & Expiration date 03/31/2017
Are you currently involved in community service related to your position as a health care provider?
Examples might include working with a free clinic, conducting health outreach, or working with a local health related agency.
Yes No
If yes, please describe how you are involved in community service related to your position as a health care provider.
Alumni Survey Part One OMB # 0915-0376 & Expiration date 03/31/2017
Loan Repayment
Have you participated in a loan repayment program since finishing your primary care residency?
Yes No
Other (please specify)
If you have received any kind of loan repayment since completing your primary care residency program, please indicate the type of loan repayment program. Please choose all that apply.
Armed Forces (Air Force, Army or Navy) Health Professions Loan Repayment Program Department of Education’s Public Service Loan Forgiveness
Health Resources and Services Administration (HRSA) Faculty Loan Repayment Program Hospital Program (e.g. sign-on bonus)
Indian Health Service (IHS) Loan Repayment Program National Health Service Corps Loan Repayment
National Health Service Corps Students to Service Loan Repayment Program National Institutes of Health (NIH) Loan Repayment Programs
State Loan Forgiveness Program (e.g. Health Professions Loan Assistance Program)
Contact Information
Alumni Survey Part One OMB # 0915-0376 & Expiration date 03/31/2017
Name:
Address:
Address 2:
City/Town:
State: -- select state --
ZIP:
Country:
Email Address:
Phone Number:
Please provide any updates in your contact information: