Ethnio Screener

Your experience certifying Massachusetts Paid Medical Leave for patients

We value your time. This is all we need to know

Intro

We're a public benefit corporation working with the Massachusetts Department of Family and Medical Leave to understand how healthcare providers fill out the Certification of Your Serious Health Condition on behalf of patients who need medical leave. We're looking for participants who can provide feedback on the form to make sure we’re on track to build a service that works for everyone.

Please answer a few questions to help us ensure we're hearing from healthcare providers in many specialties, of all personal backgrounds, and who serve patients of all backgrounds. Your answers are only viewable by our research team.

We will conduct research sessions on a regular basis over the next few months. If you’re selected, you will receive an email from one of our researchers to schedule a time to speak with us.

Name*

Email (used only to match to our conversations)*

Phone (only used for interview reminders)*

What is your area of practice? (This includes medical specialties, physical and psychological therapies, etc.)

Do you ever complete Certification of Your Serious Health Condition forms on behalf of patients applying for Massachusetts Paid Family and Medical Leave? Click to download this form for reference. *

Yes

If yes, what best describes your role in completing these kinds of documents?

I generally fill in and sign these documents.

I generally fill in answers and give the document to a practitioner to sign.

I review and sign the paperwork but someone else in my practice generally fills in answers beforehand.

Other

If yes, have you ever had to later correct a Certification for Your Serious Health Condition, which you had previously filled out?

Yes

Do any of the following apply to your patients or clients? Check all that apply.

Many of my patients are members of less-represented ethnic or racial communities, including Black people, Latinx people, Asian people, and other people of color

Many of my patients have limited English proficiency

I serve patients of many gender identities

Many of my patients are people with disabilities

What's your gender?

Are you of Hispanic, Latino, or Spanish origin?

Yes

How would you describe your race?

Do you use any assistive tools, like a screen reader, when you use the internet? If so, what assistive tools do you use?

When are you available for a 1-hour Zoom interview?

Oops looks like there are no longer available times.