Welcome to the Harvard Study of Physician Involvement with Public Life! Before we start, please look over this informed consent form that you received with the survey. Then answer the question below. Has the nature and purpose of this research have been sufficiently explained and do you agree to participate? (Check one) Yes No PART I: YOUR BACKGROUND: WE WOULD LIKE TO BEGIN BY ASKING YOU SOME QUESTIONS ABOUT YOURSELF. 1.
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Are you a medical student, a resident, or have you completed your training? What is your specialty?__________________________________ What is your gender? 4.
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What is your year of birth? 1 9 Imagine that the figure below is a diagram of you. The middle circle (6) is made up of qualities or characteristics that are very central to your sense of who you are as a person. The next circle (5 or 4) is made up of qualities that are quite central to your sense of self, and the outer circle (3 or 2) is made up of qualities that are somewhat important to your sense of self. Qualities that are not part of your sense of identity belong outside the circles (1). If a quality seems good or desirable to you but isn’t an important part of who you are, you should answer “Not central to my sense of self”(1). Please think about this figure as you rate these items. Most people will use a variety of answers, rating some qualities as very central and others as less central to their sense of self. To get a good idea of how you will compare and rate the different qualities, please read all of the items before you go back to rate each of them. How important to your sense of who you are is each of the following characteristics or qualities? Not at all central to my sense of self Guided by spirituality or religious faith
Smart or intellectually capable
Concerned about international issues
Fair, unbiased
Willing to stand up for what I believe is right
Involved in solving community problems
Creative or imaginative
Politically involved
Compassionate, concerned about all kinds of people
Honest or truthful
Concerned about government decisions and policies
Unconventional, nonconformist
Concerned about justice and human rights
Responsible, someone others can depend on
Outgoing or sociable Someone who helps others
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Extremely central to my sense of self 2 2 2 2 2 2 2 2 2 2 2 2 2
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Since what year have you been living in your present city or town? ____________ 7.
Which category best describes your racial background? 8.
Which of the income groups below includes the total 2008 income before taxes of all members of your family living in your home? Please include salaries, wages, pensions, dividends, interest, and all other income. (If uncertain: what would be your best guess?) 9.
Last week, were you: (Check one.) 10. What is your family status? 11. How many children live at home with you? _________How many of these children are under age 5?_________ PART II: IN THIS SECTION, WE WOULD LIKE TO ASK YOU ABOUT YOUR GENERAL INVOLVEMENT IN PUBLIC LIFE. 12. We hear a lot of talk these days about liberals and conservatives. Here is a scale on which the political views that people might hold are arranged from extremely liberal to extremely conservative. Where would you place yourself on this scale? 13. How interested are you in politics and current affairs? 14. How much influence do you think someone like you can have over government decisions? 15. Some people are not able to vote because they're not registered, they don't have time, or other reasons. Think about national elections held since you were old enough to vote. How often have you voted? 16. Generally speaking, I consider myself a…. 17. Below is a list of things that some people have done to express their views or take social or political action. Some people have not done any of these things. Others have done many of them. For each item, please indicate how often you have done it in the past 2 years. In the past 2 years, I have…. Discussed political problems with friends
Worked together with someone or some group to solve a problem in the community where I live
Contacted or visited a public official ‐ at any level of government ‐ to ask for assistance or to express my opinion
Contacted a newspaper or magazine to express my opinion on an issue
Called in to a radio or television talk show to express my opinion on a political issue, even if I did not get on the air
Attended a speech, informal seminar, or teach‐in about politics
Taken part in a protest, march, or demonstration
Signed a written or e‐mail petition about a political or social issue
Worked or volunteered for a campaign or political official
NOT bought something or boycotted it because of conditions under which the product is made, or because I dislike the conduct of the company that produces it
Bought a certain product or service because I like the social or political values of the company that produces or provides it
Worn a campaign button, put a sticker on my car, or placed a sign in front of my house
Donated money to a political candidate or cause
Never Rarely Occasionally Often Regularly 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 1 1 1 2 2 2 2 3 3 3 3 4 4 4 4 5 5 5 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 18. Some people like belonging to civic and political organizations that bring people together around a common issue, cause, identity group, or other common interest. Examples include groups like religious organizations, MoveOn, AARP, NAACP, AMA, political parties, etc. Other people do not like being part of these organizations. How many groups like this are you part of?____________________________________________________________ In how many of these groups do you actively participate?________________________________________________ In how many of these groups have you held leadership positions (now or in the past)?_________________________ About how many hours per month would you say you devote to these kinds of groups?________________________ 19. We've been asking you about recent political activity. Was there a time in the past when you were more active in politics than you are at present? PART III: YOU’RE ALMOST DONE! IN THIS FINAL SECTION, WE WOULD LIKE TO ASK YOU ABOUT YOUR INVOLVEMENT, HOWEVER MINIMAL, WITH AN ORGANIZATION CALLED DOCTORS FOR AMERICA (DFA). PLEASE ANSWER ALL THE QUESTIONS AS BEST YOU CAN. 20. How did you first hear about Doctors for America (DFA)? 21. Which of the statements below best characterizes your impression of DFA? 22. Since joining, about how many online actions (such as signing a petition, sending a letter to Congress, etc.) have you done? _____________ 23. Since joining, about how many face‐to‐face events have you attended?_____________ 24. Are your friends, colleagues, or other people you know part of the organization? (If yes, about how many friends or colleagues are part of DFA?_______________) Yes No Not Sure 25. Please indicate which statement below best characterizes your interactions with people in the organization since you joined. 26. Do you know who any of the local leaders of DFA are in your area? Yes No (If yes, please indicate who that person is:_____________________________________________) 27. We are interested in knowing about whether people are drawn into DFA by others. Did someone ask you to do each of the things below? For each one, please indicate whether someone ever asked you to do each activity, how they asked you (if applicable), and what your relationship to that person was (if applicable). Join the organization Take actions, like petitions, writing letters, etc. Take part in face‐to‐face events w/others Did someone ask you? How did s/he ask you? Did you know the person? ___________________________ ___________________________ ONLY ONE MORE PAGE! What was your relationship to that person? ___________________________
28. People get involved with organizations like DFA for many different reasons. Below is a list of some reasons people have given us. Thinking about your decision to get involved with DFA, please indicate how important each of these reasons was to you. Not at all Slightly Somewhat Fairly Extremely I got involved with DFA…. important Important Important Important Important …to be part of an organization that stands for the right ideals. 1 2 3 4 5 …to become a leader in my community. 1 2 3 4 5 …to meet other doctors. 1 2 3 4 5 …to fight for healthcare reform. 1 2 3 4 5 …to help others in need. 1 2 3 4 5 …to build skills that are valuable in other aspects of my life.
1 2 3 4 5 …because I have always been interested in medicine and public policy.
1 2 3 4 5 …because I found it exciting. 1 2 3 4 5 …because I wanted to learn about politics and government. 1 2 3 4 5 …to join with people who share my ideals. 1 2 3 4 5 …to meet important and influential people. 1 2 3 4 5 …to influence public policy. 1 2 3 4 5 …because it was my duty as a citizen. 1 2 3 4 5 …to further my job or career. 1 2 3 4 5 …to gain recognition from people I respect. 1 2 3 4 5 …because I might want a job with the government or run for office some day. 1 2 3 4 5 …to be with people I enjoy. 1 2 3 4 5 …because I did not want to say no to someone who asked. 1 2 3 4 5 …to become a more effective advocate/activist/leader. 1 2 3 4 5 …to make the community or nation a better place to live.
1 2 3 4 5 …to further the goals of my political party. 1 2 3 4 5 …because I am the kind of person who does my share. 1 2 3 4 5 …to access resources to make a difference. 1 2 3 4 5 …to change public opinion. 1 2 3 4 5 …because I am a joiner. 1 2 3 4 5 …because I was frustrated with the status quo in medicine.
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29. What other reasons that we have not already mentioned do you have for getting involved with DFA? _______________________________________________________________________________________________ 30. Do you have others thoughts or comments about your own involvement in public life, or physicians’ involvement in public life that you would like to share? _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ Would you be willing to be contacted for a follow‐up interview? Yes No If yes, please indicate the best way to contact you (email and/or phone)_______________________________
THANK YOU VERY MUCH FOR YOUR PARTICIPATION IN THIS STUDY! Submit by Email
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