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

Estimated Number of African American Patients or Families members Physician treats

or
Estimated Percent of 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

NPFR Affiliate Programs

CBO Coalition: if you are a member of an African American organization with health focused activities, and would be interested in partnering with 50 Hoops or NPFR for an event in your city