Form 4 Appendix D: Individual Respondent Characteristics (Admin

Appendix D – Individual Respondent Characteristics (Administrators)

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

Diagnostic Safety Capacity Building – TeamSTEPPS® Resource

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

Individual Respondent Characteristics Survey (Administrators)

Characteristic	Response Option*
Participant Category	Provider Staff Administrator Other: _________________
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
Education Level	Elementary High School Diploma Some College Associate degree Bachelor’s degree Master’s degree Professional Degree Doctorate
Age	Age (years): ___________
Location	City, State: ___________________________
Setting Type	Office-based practice Primary Care Specialty Care FQHC Multispecialty Urgent Care Center Skilled Nursing Facility Hospital Other: ____________________________
*Each characteristic must include an option for did not respond/did not provide an answer

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