Medical Office Information Form

To be completed by a single office point of contact for each medical office submitting data to the Medical Office Survey on Patient Safety Culture Comparative Database.

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Instructions: Please provide the following information, which will be used to produce descriptive statistics and analyze data in aggregate collected with the Medical Office Survey on Patient Safety. Please refer to the Data Use Agreement for assurances regarding the confidentiality and use of this data at http://www.ahrq.gov/qual/mosurvey11/mosopsdua.pdf (140 KB; Plugin Software Help). If you need assistance in answering any of the questions, please Email DatabasesOnSafetyCulture@ahrq.hhs.gov.

Public reporting burden for this collection of information is estimated to average 5 minutes per response, the estimated time required to complete the questions. 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 (0935-0196) (Expiration date 6/30/2015), AHRQ, 540 Gaither Road, Room #5036, Rockville, MD, 20850.

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Name of Office Point of Contact: (First) _________________________    (Last) _________________________
Job Title: _________________________
Name of Office: _________________________
Office Mailing Address: (Street) _________________________    (City) _________________________
(State) _________________________   (Zip code _________________________
POC Phone: _________________________    Fax: _________________________
Email: _________________________

1. Which best describes the majority ownership of this medical office/practice?
___ 1 Provider(s) and/or Physician(s)
___ 2 University or Academic Medical Institution
___ 3 Hospital or health system
___ 4 Community health center
___ 5 Other, please specify:__________________________________________________

2. Total number of employees asked to complete the survey? _______

3. What was the mode used to administer the survey?
___ 1 Paper only
___ 2 Web only
___ 3 Mixed mode (paper and Web)

4. When did your medical office finish its administration of the Medical Office Survey on Patient Safety Culture?
_________ month _________ year

5. What is the total number of providers (MDs, DOs, PAs, NPs, etc.) working in this medical office location during a typical week?
_________ total number of providers working during a typical week

6. To what extent has this medical office implemented the following electronic (computer-based) tools? (By implemented, we mean the office has the tool capability and is using it.)

Tool	Not implemented & no plans to implement in the next 12 months	Not implemented but implementation planned in the next 12 months	Implementation in process (only partial implementation)	Fully implemented
a) Electronic appointment scheduling	___ 1	___ 2	___ 3	___ 4
b) Electronic ordering of medications (with pharmacies capable of processing electronic orders)	___ 1	___ 2	___ 3	___ 4
c) Electronic ordering of tests, imaging, or procedures (with test/imaging centers capable of processing electronic orders)	___ 1	___ 2	___ 3	___ 4
d) Electronic access to your patients' test or imaging results	___ 1	___ 2	___ 3	___ 4
e) Electronic medical/health records (EMR/EHR)	___ 1	___ 2	___ 3	___ 4

7. Check the type of specialty(s) that are practiced by all providers in your medical office. By providers, we mean physicians (MDs and DOs), physician assistants (PAs), and nurse practitioners (NPs) who diagnose, treat patients, and prescribe medications.
(Mark all that apply)

___ 1. Allergy/Immunology
___ 2. Anesthesiology
___ 3. Cardiology
___ 4. Child & Adolescent Psychiatry
___ 5. Dermatology
___ 6. Diagnostic Radiology
___ 7. Emergency Medicine
___ 8. Endocrinology/Metabolism
___ 9. Family Practice/Family Medicine
___ 10. Forensic Pathology
___ 11. Gastroenterology
___ 12. General Practice
___ 13. General Preventive Medicine
___ 14. General Surgery
___ 15. Geriatrics
___ 16. Hematology/Oncology
___ 17. Internal Medicine
___ 18. Medical Genetics
___ 19. Nephrology
___ 20. Neurology
___ 21. Nuclear Medicine
___ 22. OB/GYN or GYN
___ 23. Ophthalmology
___ 24. Orthopedics
___ 25. Otolaryngology
___ 26. Pathology—Anatomic/Clinical
___ 27. Pediatrics
___ 28. Physical Medicine & Rehabilitation
___ 29. Psychiatry
___ 30. Public Health & Rehabilitation
___ 31. Pulmonary Medicine
___ 32. Radiology
___ 33. Rheumatology
___ 34. Surgery (All)
___ 35. Urology
___ 36. Vascular Medicine
___ 37. Other specialties

Current as of July 2012

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Internet Citation:

Medical Office Information Form. July 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/mosurvey11/medofficeform.htm

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