ACP American College of Physicians - Internal Medicine - Doctors for Adults

Your contact information:

Your personal information:

2. Gender: Male female

3a. Which of the following racial category best describes you?

American Indian/Alaska Native

Asian

Black/African American

White

Native Hawaiian/Other Pacific Islander

Other

3b. Your ethnicity: Hispanic Not Hispanic

Your professional information

4. Specialty/Subspecialty:

5. Are you affiliated with an Institutional Review Board (IRB)?
Yes No

6. Are you covered by a Federal Wide Assurance?
Yes No

7. Have you ever participated in an established PBRN?
Yes No

8. At how many different office locations do you see ambulatory patients?
Number of office locations:

9. Who owns your main practice (where you see the most patients)?

Physician/physician group

Hospital

Other health care corporation

HMO

Other (explain):

10. How large is your main practice (where you see the most patients)?

11. How many patients do you see in an average week?
On average patients per week

12. Does the practice you work in have a computer?
Yes No

13. Please list your research experience and research interests:

Please estimate the percentage of your patients who meet the following criteria: (please write numbers in the boxes)

Gender: % Male % Female

Race:

% American Indian/Alaska Native

% Asian

% Black/African American

% White

% Native Hawaiian/Other Pacific Islander

Payor:

% Medicaid

% Medicare

% Private Insurance

% HMO

% Self Pay

% Other