<p>Appendix A KING FAISLA SPEACIALSIT HOSPITAL AND RESEARCH CENTRE CENTER FOR CLINICAL STUDIES AND EMPIRICAL ETHICS</p><p>Dear Respondent,</p><p>We are inviting you to participate in a research project to study physician’s views towards medical chaperoning (i.e. the presence of a third party during a medical encounter with a patient of the opposite gender). Along with this letter is a survey tool that asks a variety of questions about your characteristics and chaperoning practices. We are asking you to look over the questionnaire, if you choose to do so, complete it and leave it at the grand round reception desk or mail it to the following internal mail address: MBC#03 CCSEE, Research Centre.</p><p>The survey should take a maximum of 5 minutes of your time to be completed. Your response will not be linked to you personally and all information will be used in a highly confidential manner. We hope you will take the time to complete this questionnaire. Your participation is essential but voluntary. Regardless of whether you choose to participate or not, please let us know if you would like a summary of the findings. </p><p>This project has been approved by the Research Advisory Council at KFSH&RC. </p><p>Sincerely,</p><p>Centre for Clinical Studies and Empirical Ethics</p><p>Page 1 of 3 Demographics: 1. Age (yrs):  <30  30-39  40-49   50 2. Gender:  M  F 3. Years in Clinical Practice (yrs): <5yrs  5-14 yrs 15-24 yrs  25 yrs 4. Position:  Consultant  Associate  Assistant  Fellow  Resident 5. Average number of patients you see weekly in your clinic: :  <50  50-99 100-149  150 6. Do you require a translator?  Yes  No 7. Country of post graduate training: ______8. Name of department / section: ______9. Do you perceive a chaperone as a physician protection method?  Yes  No 10. Do you perceive a chaperone as a patient protection method?  Yes  No 11. How often do you have a staff nurse available in your clinic?  >90%  >75-90%  >50-75%  > 25-50%   10-25%  < 10%. 12. How often do your patients ask for a chaperone to be present during their clinic visit?  >90%  >75-90%  >50-75%  > 25-50%   10-25%  < 10%. 13. How often have you offered your patients a chaperone to be present during their clinic visit?  >90%  >75-90%  >50-75%  > 25-50%   10-25%  < 10%. 14. How often do you use a chaperone in your clinic(s)?  >90%  >75-90%  >50-75%  > 25-50%   10-25%  < 10%. If you tick >25% for question 14 please answer questions 15, 16, & 17 only. If you tick  25% for question 14 please answer questions 18 only. 15. What type of chaperone is most frequently available in your clinic? (choose one please) staff nurse patient’s maid medical resident other hospital staff (i.e. patient’s relative translator, clerk, none patient’s friend clinical member of staff, etc)</p><p>Page 2 of 3 others______(sp ecify)</p><p>Page 3 of 3 When do you use a chaperone? (you can choose more than one)  during a medical interview  during a medical exam: (Please specify)</p><p> General (heart lung</p><p>abdomen) breast ○genitals (pelvic/testicular) ○rectal  during a procedure (ex. Endoscopy) 16. Reasons for using a chaperone: Patient factors: (Please specify, you can choose more than one) Social norm Patient expectations Patient preference  Patient (request) psychiatric/psychologic Patient anxiety al history Other, (specify):______Physician factors: (Please specify, you can choose more than one) Ethical (not related Physician comfort to religion) Common practice Religious Technical assistance Fear of litigation Other (specify):______17. Reasons for not using a chaperone: (you can choose more the one) No stated policy Not beneficial to patient-doctor No need to use a chaperone relationship</p><p>(personal opinion)  Patient’s preferences (○Psychological </p><p>Time constraints reasons ○Embarrassment)  Cost constraints Patient’s privacy/confidentiality Availability issues</p><p>Page 4 of 3</p>