"Evaluation of Pharmacy Syringe Access Linked to HIV Testing for Injection Drug Users in New York City (Pharm-HIV)" - Pharmacy Staff Baseline Survey (Pharmacist)
Evaluation of Pharmacy Syringe Access Linked to HIV Testing for Injection Drug Users in New York City (Pharm-HIV)
09AF_Att3a_Pharmacy Staff Baseline Survey
"Evaluation of Pharmacy Syringe Access Linked to HIV Testing for Injection Drug Users in New York City (Pharm-HIV)" - Pharmacy Staff Baseline Survey (Pharmacist)
OMB: 0920-0837
Form Approved
OMB No. 0920-09XX
Exp Date: XX/XX/XXXX
“Evaluation of Pharmacy Syringe Access Linked to HIV Testing for Injection Drug Users in New York City (Pharm-HIV)”
Pharmacy Staff Baseline Survey
Public reporting burden of this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a persons is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: PRA (0920-09XX)
_____________________________________________________________________________________
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service
Centers for Disease Control and Prevention
Atlanta, Georgia 30333
Pharmacy Sales and Experience
Baseline Survey
Version 1.0
Date: ______________ Start Time: ___ ___ :___ ___ AM / PM End Time: ___ ___ :___ ___ AM / PM
Interviewer ID #: _______ Participant ID # ______________
INTERVIEWER READ:
I am going to start by asking some questions about you.
What is your gender?
Male … 0
Female …1
2.a. Do you consider yourself to be Hispanic or Latino?
01 Yes
02 No
b. What race do you consider yourself (check all that apply)?
Black or African-American [A7b]
White [A8]
Asian [A8]
Native Hawaiian or Other Pacific Islander [A8]
American Indian or Alaskan Native [A8]
- - Refused [A8]
++ Don’t know [A8]
What country are you from (ask open-ended)?
Besides English, what languages do you speak?
Language Options to be shown on screen, along with option to type in “Other” language: Spanish, Chinese (Cantonese/Mandarin or other), Russian, Haitian Creole, Korean, Bengali, Arabic, Urdu, Polish, French Vietnamese, Other
Don’t Know … 8
Refused … 9
How many total years (or months) have you worked in pharmacies (Probe: the pharmacy you currently work at and any before that)?
____ ____ # #Years ____ ____ # # Months
Don't know … 888
Refused … 999
How many years (or months) have you worked at this pharmacy?
____ ____ . ____ ____ # #Years
[1 month = 0.08 years; 4 months = 0.33 years, etc]
Don't know … 888
Refused … 999
What is your position … (read if needed)
Owner (Pharmacist) … 0
Managing or supervising pharmacist … 1
Staff pharmacist … 2
Owner (non-pharmacist) … 3
Manager (non-pharmacist) … 4
Technician/Clerk … 5
Don't know … 8
Refused … 9
How many hours a week do you work at this pharmacy?
___ ___ [##Hours]
Don’t Know … 888
Refused … 999
SKIP PATTERN:
If pharmacist [Q6, responses 0-2] go to Q9
If owner/manager non-pharm, Clerk/tech [Q7, responses 3-5] Go to Q12
In what year did you first obtain your license to practice pharmacy?
___ ___ ___ ___
YYYY
[If no pharmacy license, enter “0000”]
Don't know … 888
Refused … 999
INTERVIEWER READ: I am now going to ask you some questions about your pharmacy.
Which of the following best describes this pharmacy?
Independent … 0
Chain … 1
Independently-owned franchise … 2
Hospital pharmacy … 3
Other (please specify) _________________________ … 4
Don’t Know … 8
Refused … 9
How many full-time and how many part-time pharmacists are employed? (Probe: Including you, if pharmacist) [Full-time means 35 or more hours per week]
Full-time ____ ____ # #
Part-time ____ ____ # #
Don’t Know … 888
Refused … 999
What are the hours of operation? (If 24 hours enter 00 to 24)
a. Weekday ___ ___ :___ ___ AM / PM to ___ ___ :___ ___ AM / PM
b. Saturday ___ ___ :___ ___ AM / PM to ___ ___ :___ ___ AM / PM
c. Sunday ___ ___ :___ ___ AM / PM to ___ ___ :___ ___ AM / PM
Don’t Know … 888
Refused … 999
About how many prescriptions does your pharmacy fill in a week?
< 100 … 0
100-250 … 1
251-500… 2
>500… 3
Don’t Know … 888
Refused … 999
When did your pharmacy register for ESAP?
__ __ / __ __
M M / Y Y
Don’t know …888
Refused … 999
Do you have an ESAP decal displayed in the window or door of your pharmacy? (Probe: This is a sticker with the ESAP logo on it that the Department of Health should have sent you when you registered.)
No … 0
Yes [SKIP to 17] … 1
Don't know … 8
Refused … 9
Why isn’t the decal displayed in your window or door? [Ask open-ended and circle all that apply]
Didn’t get around to putting it up … 0
Not necessary … 1
Don’t want too many ESAP customers … 2
People already know … 3
Misplaced decal … 4
Forgot to put it up…5
Never received it … 6
Other (Please specify)_________________________________________… 7
Don't know … 8
Refused … 9
Are the following products or services available in your pharmacy? [read responses]
|
No |
Yes |
Don't know |
Refused |
a. Non-prescription syringes in packs of 10 |
0 |
1 |
8 |
9 |
b. Individual non-prescription syringes (singles) |
0 |
1 |
8 |
9 |
c. Personal sharps disposal containers for retail sale |
0 |
1 |
8 |
9 |
d. Accept syringes for biohazard disposal |
0 |
1 |
8 |
9 |
How often do you counsel or advise customers in your pharmacy on [read responses]:
|
Never |
A few times/ mo |
A few times/ week |
At least once a day or more |
Don’t Know |
Refused |
A. Prescription medications |
0 |
1 |
2 |
3 |
8 |
9 |
B. Medical conditions |
0 |
1 |
2 |
3 |
8 |
9 |
C. Health insurance |
0 |
1 |
2 |
3 |
8 |
9 |
D. Other products in pharmacy |
0 |
1 |
2 |
3 |
8 |
9 |
G. Any other discussion/ counseling |
0 |
1 |
2 |
3 |
8 |
9 |
H. If other please describe: ___________________________________________
How interested or receptive do you think customers are to information and referrals on [read responses] Receptive:
|
Very Receptive |
Somewhat Receptive |
Not Receptive |
Don't know |
Refused |
A. Prescription Medications |
0 |
1 |
2 |
8 |
9 |
B. Medical conditions |
0 |
1 |
2 |
8 |
9 |
C. Health insurance |
0 |
1 |
2 |
8 |
9 |
D. Other products in pharmacy |
0 |
1 |
2 |
8 |
9 |
G. Other discussion/ counseling |
0 |
1 |
2 |
8 |
9 |
How much do you support the following services being provided in your pharmacy? (Probe: Hypothetically, that is, even if it isn’t feasible, how supportive would you be if it were?)
|
Very Supportive |
Somewhat Supportive |
Not Supportive |
Don't know |
Refused |
|
0 |
1 |
2 |
8 |
9 |
|
0 |
1 |
2 |
8 |
9 |
|
0 |
1 |
2 |
8 |
9 |
|
0 |
1 |
2 |
8 |
9 |
|
0 |
1 |
2 |
8 |
9 |
Have you ever discussed HIV testing with customers?
Yes … 0
[IF NO SKIP TO Q25] No … 1
Don't know … 8
Refused … 9
Have you ever discussed HIV testing with an ESAP syringe customer?
Yes … 0
[IF NO SKIP TO Q25] No … 1
Don't know … 8
Refused … 9
How often do you talk to your ESAP customers about HIV testing?
Very Rarely… 0
About once/month… 1
A few times/month… 2
A few times/week… 3
Once a day or more… 4
How receptive do you think your ESAP customers are to information you give them about/ discussion of HIV testing?
Very Receptive… 0
Somewhat Receptive… 1
Not Receptive… 2
Don't know… 3
Refused… 4
In the neighborhood of the pharmacy, would you estimate the level of illegal drug activity to be [read responses]
Very high … 0
High … 1
Moderate … 2
Low … 3
Virtually none … 4
Don't know … 8
Refused … 9
INTERVIEWER READ: Now I’m going to ask some questions about your syringe sales over the past month.
About how many non-prescription syringes were sold in your pharmacy in the past week?
Individual Syringes ____ ____ ____ # #
Don't know … +++
Refused … - - -
About how many non-prescription syringes have you personally sold in the last week? (PROBE: how many syringe sales transactins did you handle in the past 7 days? If on vacation/ sick/ no working during past week, then in the last full week workd.)
Individual Syringes ____ ____ ____ # #
Don't know … +++
Refused … - - -
About how many prescription syringes have you sold in the last week?
Individual Syringes ____ ____ ____ ____ # #
[1 box = 100 syringes; 1 mo Rx = 30 syringes]
Don't know … +++
Refused … - - -
In an average month, about how many ESAP or non-prescription syringe customers came to purchase syringes? (Probe: think of average monthly sales over the past 3 months)
___ ___ ___ / Month
Don’t Know … 888
Refused … 999
29. Thinking of this average monthly number of ESAP (non-prescription) syringe customers…
a. About how many are NEW? (Probe: someone who had never bought syringes before at your pharmacy)
___ ___ ___ / Month
Don’t Know … 888
Refused … 999
b. About how many would you consider repeat/regular?
___ ___ ___ / Month
Don’t Know … 888
Refused … 999
Which age group are most of your ESAP ( non-prescription) syringe customers? [read responses]
18-25 …0
26-40 … 1
41-55 … 2
56 and Over … 3
Don’t Know … 8
Refused … 9
Which racial/ ethnic group are most of your ESAP (non-prescription) syringe customers? [read responses]
American Indian or Alaska Native … 0
Asian … 1
Black or African-American … 2
Hispanic or Latino.… 3
Native Hawaiian or other Pacific Islander … 4
White … 5
Don’t Know … 888
Refused … 999
What percentage of your ESAP (non-prescription) customers do not speak English well?
All customers speak only English … 0 (Skip to 34)
1-25% … 1
26-50% … 2
51-75% … 3
>76% … 4
Don’t Know … 8
Refused … 9
33. What are the other languages besides English spoken by your customers? (Ask open ended and select all languages given. Language Options to be shown on screen, along with option to type in “Other” language: Spanish, Chinese (Cantonese/Mandarin or other), Russian, Haitian Creole, Korean, Bengali, Arabic, Urdu, Polish, French, Other)
Don’t Know … 8
Refused … 9
Of your pharmacy’s non-prescription syringe customers over the past month, do you think any of them inject … ? [read responses]
|
No |
Yes |
Don't know |
Refused |
|
0 |
1 |
8 |
9 |
|
0 |
1 |
8 |
9 |
|
0 |
1 |
8 |
9 |
|
0 |
1 |
8 |
9 |
Of the staff in your pharmacy, who is most likely to make a syringe sale?
Yourself …1
All pharmacists equally … 2
All Clerks/Techs Equally … 3
All Staff Equally … 4
Other (Please Specify) ____________________________________ … 5
Don't know … 8
Refused … 9
Of your ESAP customers over the past month, about how many did you have a conversation with?
____ ____ # # customers
[If 00, Skip to Question 38]
Don't know … 888
Refused … 999
What do you talk about? [Do not prompt. Ask open-ended & circle all that apply.]
Drug treatment … 1
Safe injection practices … 2
Disposal of syringes … 3
What syringes will be used for … 4
Prescription Medications … 5
Health concerns … 6
Health Insurance … 7
Other Products in Pharmacy … 8
Friendly greetings (nothing specific) … 9
HIV testing/issues relating to HIV/AIDS …10
Other (Please Specify) ______________________________________ … 10
Don't know … 88
Refused … 99
|
No |
Yes |
Don't know |
Refused |
|
0 |
1 |
8 |
9 |
|
0 |
1 |
8 |
9 |
|
0 |
1 |
8 |
9 |
Since you began selling non-prescription syringes, have you noticed increases with any of the following that you would attribute to non-prescription syringe sales?
39. Do you think that selling syringes to injection drug users…
|
No |
Yes |
Undecided |
Refused |
|
0 |
1 |
2 |
9 |
|
0 |
1 |
2 |
9 |
|
0 |
1 |
2 |
9 |
|
0 |
1 |
2 |
9 |
40. How would you rate your relationship with ESAP customers [read responses]?
Very Trusting … 1
Somewhat Trusting … 2
Not trusting at all … 3
Don't know … 8
Refused … 9
Open-ended questions
41. What are your main concerns about syringe sales at your pharmacy? Are there any issues, unusual events or concerns that you would like to describe? (If disposal is an issue, ask: how would you like to see this problem addressed?)
Skip Pattern: Pharmacists, Managers and Owners only answer Q40
42. Why did you initially register for ESAP?
43. How do you get information, answers to questions/concerns about the program?)
| File Type | application/msword |
| File Title | Pharmacist Survey |
| Author | liza vadnai |
| Last Modified By | tfs4 |
| File Modified | 2009-09-03 |
| File Created | 2009-09-03 |
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