Physician Survey Form


Your Name    (required)
Contact Date
Physician Name    (required)
Affiliations
Street Address
City
State
Zip
Office Phone    (required)
Office Contact Name    (required)
Fax Number
Position of Contact Person
Email
Estimated Number of African American Patients or Families members Physician treats  
or
Estimated Percentof African American Patients or Families   
Follow Up Date
Notes/Comments

Which Diseases do you treat

Diabetes
High Blood Pressure
Cardiovascular Disease
Asthma
Heart Disease
HIV-AIDS
Prostate Cancer
Breast Cancer
Colon Cancer
Cervical Cancer
Kidney Cancer
Obesity 

Disclaimer: The National Physician and Family Referral Project (NPFR) is a national minority patient/ physician/ community outreach project that focuses upon racial disparities in health care, patient health and clinical trials education. NPFR partners with 50 Hoops, P&E Associates and networks with hundreds of African Americans organizations. Through media, community-based networks, national disease-related projects and coalitions, NPFR utilizes public service media outreach to educate and surveys to evaluate effectiveness of educational programs. The information we gather is voluntary and confidential, and will not be used for public or media dissemination. This information will be used for scientific and medical research to help identify and eliminate racial disparities in health care and disparities related to inclusion of minorities in clinical trials.

By answering these questions, you are agreeing that you are voluntarily offering important historic research data, and that no pay is/has been promised now or in the future for your participation in this project. You agree to hold harmless 50 Hoops, the NPFR, it's partners, associates, clients, employees, affiliates and consultants from and against all claims arising from use of this information for medical research or other medical clinical studies for which the physician or patient may be contacted, or for personal or medical release.

If you have any questions, call 1-800-677-8441

Contact Us

National Physician and Family Referral (NPFR) Project
14902 Preston Road, #404-744, Dallas, TX 75254
1-800-677-8441
See also: http://www.africanamericanhealthmatters.com

STAY HEALTHY where it matters
Register to participate to get mobile health tips of your choice on your cell phone

Educational Outreach Components

The CEDRICT project has developed a patient and community health education project entitled: "African American Health Matters", a mobile text message service that reminds subscribing African Americans of all ages about health matters critical to their daily lives. The Mobile Health Text Message Service kicked off September 19, 2009 with nearly 5,000 ground-zero subscribers. In less than a year over 50,000 subscribers receive monthly and bi-monthly health tips messages. The companion web site, http://www.africanamericanhealthmatters.com, allows the health text message service to tap into a younger group of African Americans, and the professionals, educators and black entrepreneurs.



AACT I Lecture Series 2012