Form #3 Form #3 Social Network Analysis Questionnaire

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Testing the Spread & Implementation of Novel MRSA-Reducing Practices

You are being asked to voluntarily participate in a research study. The purpose of this study is to understand the structure of the network of individuals working to reduce MRSA in your hospital. Hospital employees that affect the work on your unit who are involved in direct patient care activities or assist with patient care activities, such as nurses, physicians, environmental services employees, administrative staff, infection control staff, quality improvement staff, transport, rehabilitation, respiratory therapists, pharmacists, radiologists, and all others, can voluntarily participate in the study by completing this survey.

If you choose to participate in the study, please fill out the attached survey; it will take between ten and fifteen minutes. This survey is made up of questions that ask about your primary communication network at work and your MRSA reduction-related communication network. Please answer the questions by filling out the blanks or checking the appropriate boxes.

Minimal risks are involved. If you choose to participate, you have the right to withdraw from the study at any time, without any negative consequences or repercussions. Confidentiality of your answers will be maintained. This network analysis asks who (and how often) you communicate with in the course of performing your job, who you communicate with concerning MRSA reduction activities, as well as who you communicate with relating to work advice. In order to map out who communicates to whom, we will need you to give us your name as well as other basic demographic information when filling out the survey. Once we have collected the data, we will construct a network map like this one:

Public reporting burden for this collection of information is estimated to average 15 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person 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: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

This type of map will allow us to calculate network metrics, such as “degrees of separation” between pairs of people, or the length of network paths from one person to another.

When you have completed the survey, place it in the drop-off box located in your unit.

We hope that you are interested in participating in this study. As you can see, in order for this type of map to be accurate, it is important that everyone answer ALL questions for EVERY PERSON listed on the survey as completely as possible. Thank you for your time and consideration. If you have any questions or concerns, please feel free to call XXX.

Social Network Analysis

1. Gender: Male Female

2. Please check your age group

Under 25 26-35 36-45 46-55 Over 55

3. What is the highest level of education you have completed?

High school or equivalent

Some college

Bachelor’s degree or equivalent

Master’s degree or higher

4. What is your department/unit? ________________________________________________

5. What is your current job title?

Nursing Assistant (NA or Patient Care Technician) Clinical Dietician

Licensed practical nurse (LPN) Respiratory Therapist

Physical/Occupational/Speech Therapist Environmental Services

Social Work/Case Management Registered nurse (RN)

Certified nurse practitioner (CRNP) Physician’s Assistant

Quality Control Staff/”One is too Many” Core Group Radiology Tech (X-ray)

Attending, Staff Physician, Intern, Resident, Fellow (MD) Pharmacist

Other (please specify) _______________________________________________________

6. In the past 30 days, which shift did you work most often? Day Evening Night

7. How long have you been with this department/unit? ______Years______Months

8. How long have you been with this organization? ______Years______Months

9. How long have you worked in the healthcare field? ______Years______Months

10. On average, how many hours do you currently spend in direct patient care per week?

0 1-10 11-20

21-30 31-40 More than 40 hours

11. On average, in the course of performing your job, how many hours a week do you spend

communicating with other hospital staff?

0 1-10 11-20

21-30 31-40 More than 40 hours

Getting things done at your job usually requires communication with colleagues and contacts (including face-to-face, email, telephone, etc.). For instance, these could be regular interactions you have that help you complete the tasks assigned to you. For the names listed below, please indicate how often in the PAST 3 MONTHS you communicate with or contact that person as a part of performing your basic job. Circle the appropriate number. *NOTE: Please make sure to answer EACH question for EVERY person listed, even if you never have any contact or communication with them (in that case choose the option “DO NOT contact”).
12. With whom do you communicate in the course of performing your basic job?
Name of Individual	Several Once or Several Less than DO NOT Every times a twice a times once per contact day week week a month month
Cathy A.	5 4 3 2 1 0
Dean N.	5 4 3 2 1 0
David C.	5 4 3 2 1 0
Ellen S.	5 4 3 2 1 0
Jim D.	5 4 3 2 1 0
John R.	5 4 3 2 1 0
Roger R.	5 4 3 2 1 0
Dean N.	5 4 3 2 1 0
Rhonda M.	5 4 3 2 1 0
Mohammed R.	5 4 3 2 1 0
Julio P.	5 4 3 2 1 0
Julia S.	5 4 3 2 1 0
Jasmine M.	5 4 3 2 1 0
Sayed P.	5 4 3 2 1 0
Margaret B.	5 4 3 2 1 0
Joselyn F.	5 4 3 2 1 0
Bruce W.	5 4 3 2 1 0
Maggie T.	5 4 3 2 1 0
Tan C.	5 4 3 2 1 0
Tau G.	5 4 3 2 1 0
Robin P.	5 4 3 2 1 0
Joel V.	5 4 3 2 1 0
Jose R.	5 4 3 2 1 0
Amanda A.	5 4 3 2 1 0
Horace M.	5 4 3 2 1 0
Xiang Z.	5 4 3 2 1 0
Nikki S.	5 4 3 2 1 0
Jessica B.	5 4 3 2 1 0
Isaac I.	5 4 3 2 1 0
Ralph D.	5 4 3 2 1 0
Rita V.	5 4 3 2 1 0
Kelly T.	5 4 3 2 1 0
George C.	5 4 3 2 1 0
Treavor J.	5 4 3 2 1 0
Jorge E.	5 4 3 2 1 0
Yolanda K.	5 4 3 2 1 0
Dean N.	5 4 3 2 1 0
David C.	5 4 3 2 1 0
Ellen S.	5 4 3 2 1 0
Candice F.	5 4 3 2 1 0
John Rho.	5 4 3 2 1 0
*Please see following page for a continuation of names
CONTINUED--- With whom do you communicate in the course of performing your basic job?
Name of Individual	Several Once or Several Less than DO NOT Every times a twice a times once per contact day week week a month month
Roger R.	5 4 3 2 1 0
Michelle Q.	5 4 3 2 1 0
Doreen B.	5 4 3 2 1 0
Ellen S.	5 4 3 2 1 0
Jim D.	5 4 3 2 1 0
Timothy L.	5 4 3 2 1 0
Haley G.	5 4 3 2 1 0
Timothy L.	5 4 3 2 1 0

Transmission of MRSA is a prevalent problem that is faced by many healthcare professionals today. For the names listed below, please indicate how often in the PAST 3 MONTHS you communicate with or contact that person regarding efforts to reduce MRSA transmission. Circle the appropriate number. *NOTE: Please make sure to answer EACH question for EVERY person listed, even if you never have any contact or communication with them (in that case choose the option “DO NOT contact”).
13. With whom do you communicate regarding efforts to reduce MRSA transmission?
Name of Individual	Several Once or Several Less than DO NOT Every times a twice a times once per contact day week week a month month
Cathy A.	5 4 3 2 1 0
Dean N.	5 4 3 2 1 0
David C.	5 4 3 2 1 0
Ellen S.	5 4 3 2 1 0
Jim D.	5 4 3 2 1 0
John R.	5 4 3 2 1 0
Roger R.	5 4 3 2 1 0
Dean N.	5 4 3 2 1 0
Rhonda M.	5 4 3 2 1 0
Mohammed R.	5 4 3 2 1 0
Julio P.	5 4 3 2 1 0
Julia S.	5 4 3 2 1 0
Jasmine M.	5 4 3 2 1 0
Sayed P.	5 4 3 2 1 0
Margaret B.	5 4 3 2 1 0
Joselyn F.	5 4 3 2 1 0
Bruce W.	5 4 3 2 1 0
Maggie T.	5 4 3 2 1 0
Tan C.	5 4 3 2 1 0
Tau G.	5 4 3 2 1 0
Robin P.	5 4 3 2 1 0
Joel V.	5 4 3 2 1 0
Jose R.	5 4 3 2 1 0
Amanda A.	5 4 3 2 1 0
Horace M.	5 4 3 2 1 0
Xiang Z.	5 4 3 2 1 0
Nikki S.	5 4 3 2 1 0
Jessica B.	5 4 3 2 1 0
*Please see following page for a continuation of names
CONTINUED--- With whom do you communicate regarding efforts to reduce MRSA transmission?
Name of Individual	Several Once or Several Less than DO NOT Every times a twice a times once per contact day week week a month month
Isaac I.	5 4 3 2 1 0
Ralph D.	5 4 3 2 1 0
Rita V.	5 4 3 2 1 0
Kelly T.	5 4 3 2 1 0
George C.	5 4 3 2 1 0
Treavor J.	5 4 3 2 1 0
Jorge E.	5 4 3 2 1 0
Yolanda K.	5 4 3 2 1 0
Dean N.	5 4 3 2 1 0
David C.	5 4 3 2 1 0
Ellen S.	5 4 3 2 1 0
Candice F.	5 4 3 2 1 0
John Rho.	5 4 3 2 1 0
Roger R.	5 4 3 2 1 0
Michelle Q.	5 4 3 2 1 0
Doreen B.	5 4 3 2 1 0
Ellen S.	5 4 3 2 1 0
Jim D.	5 4 3 2 1 0
Timothy L.	5 4 3 2 1 0
Haley G.	5 4 3 2 1 0
Timothy L.	5 4 3 2 1 0

For the following 2 questions, please use a check mark (next to the appropriate name/s) to mark your answer.

14. Whom do you look to or go to for ideas, inspiration, and energy around MRSA elimination?	15. With whom would you like to work in the next 3 months on MRSA prevention activities, that you have not worked with in the past?
Cathy A.	Cathy A.
Dean N.	Dean N.
David C.	David C.
Ellen S.	Ellen S.
Jim D.	Jim D.
John R.	John R.
Roger R.	Roger R.
Dean N.	Dean N.
Rhonda M.	Rhonda M.
Mohammed R.	Mohammed R.
Julio P.	Julio P.
Julia S.	Julia S.
Jasmine M.	Jasmine M.
Sayed P.	Sayed P.
Margaret B.	Margaret B.
Joselyn F.	Joselyn F.
Bruce W.	Bruce W.
Maggie T.	Maggie T.
Tan C.	Tan C.
Tau G.	Tau G.
Robin P.	Robin P.
Joel V.	Joel V.
Jose R.	Jose R.
CONTINUED…Whom do you look to or go to for ideas, inspiration, and energy around MRSA elimination?	CONTINUED…With whom would you like to work in the next 3 months on MRSA prevention activities, that you have not worked with in the past?
Amanda A.	Amanda A.
Horace M.	Horace M.
Xiang Z.	Xiang Z.
Nikki S.	Nikki S.
Jessica B.	Jessica B.
Isaac I.	Isaac I.
Ralph D.	Ralph D.
Rita V.	Rita V.
Kelly T.	Kelly T.
George C.	George C.
Treavor J.	Treavor J.
Jorge E.	Jorge E.
Yolanda K.	Yolanda K.
Dean N.	Dean N.
David C.	David C.
Ellen S.	Ellen S.
Candice F.	Candice F.
John Rho.	John Rho.
Roger R.	Roger R.
Michelle Q.	Michelle Q.
Doreen B.	Doreen B.
Ellen S.	Ellen S.
Jim D.	Jim D.
Timothy L.	Timothy L.
Haley G.	Haley G.
Timothy L.	Timothy L.

16. Which one of the following MRSA reduction activities are you most interested in working on within the next

year? (Please only choose one):

Involving the Community in MRSA reduction

Creating new educational materials

Changing supplies and arrangement of supplies

Involving patients and their families

Culture change

Talking with peers about MRSA prevention

Not interested

Other (please specify)__________________________________________________________________

18. Is there anything else concerning MRSA reduction efforts that you would like to add?

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________