Attachment G -- Patient Health Care Use Questionnaire

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

Health Care Use Questionnaire

You are being asked to voluntarily participate in a study. The purpose of this study is to understand health care use patterns and the risk of MRSA infections. The intended result of this study is to understand the risk factors for developing MRSA infections.

Individuals who have received some health care (i.e., doctor visit, dialysis, outpatient surgery) in the last 12 months can voluntarily participate in the study by completing this survey.

If you choose to participate in the study, please fill out the survey packet; it will take about

15 minutes. Please answer the questions by marking the response that best answers the question.

Minimal risks are involved. If you do not feel comfortable answering a certain question, then you do not need to answer the question. You may choose to withdraw from the study at any time.

Confidentiality of your answers will be maintained.

Public reporting burden for this collection of information is estimated to average 15 minutes per response, the estimated time required to complete the survey. 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.

Instructions

• The survey takes about 15 minutes to complete

• You can use either a pen or a pencil to mark your responses

• Your responses will remain strictly confidential and will not be shared with anyone outside the Indianapolis University-Purdue University-Indianapolis research team. Only the aggregate findings will be shared

• Questions appear on both sides of each sheet

• Please answer each question honestly. Although some questions may appear similar, every question has been selected carefully. There are no right or wrong answers

Please check the answer that best applies.	No	Yes
In the last year, did anyone in your household have a MRSA infection?	No □	Yes □
In the last year, did you share personal items (e.g. uniforms, clothes, razors, washcloths) that were used by a person infected with MRSA or a person with a history of MRSA infection?	No □	Yes □
In the last year, did you have dialysis? (Dialysis is filtration of the blood to remove toxins and perform the work that the kidney normally does.)	No □	Yes □	If you answered yes, how often did you have dialysis in the last year (check all that apply): □ three times weekly □ daily, on a temporary basis □ other frequency Was the type of dialysis called hemodialysis (where blood is removed, filtered, and replaced)?: □ Yes □ No
In the last year, did you have any outpatient surgical procedures?	No □	Yes □	If you answered yes, please provide month and year of each surgical procedure (mm/yyyy) Dates: _____________ Dates: _____________ Dates: _____________
In the last year, did you use intravenous (IV) medications at home?	No □	Yes □	If you answered yes, please provide month and year of use (mm/yyyy) and types Dates: ___________ Drug: _________ Dates: ___________ Drug: _________ Dates: ___________ Drug: _________ Dates: ___________ Drug: _________ Dates: ___________ Drug: _________
In the last year, did you have an intravenous (IV) catheter, central venous line, or chemotherapy port in place while at home?	No □	Yes □
In the past year, did you spend one or more nights in any of the following types of facilities:
Acute Care Hospital	No □	Yes □	If you answered yes, please provide dates of your stay(s) (mm/dd/yyyy to mm/dd/yyyy) Dates: _____________
Long Term Care Facility	No □	Yes □	If you answered yes, please provide dates of your stay(s) (mm/dd/yyyy to mm/dd/yyyy) Dates: _____________
Nursing Home	No □	Yes □	If you answered yes, please provide dates of your stay(s) (mm/dd/yyyy to mm/dd/yyyy) Dates: _____________
Skilled Nursing Facility	No □	Yes □	If you answered yes, please provide dates of your stay(s) (mm/dd/yyyy to mm/dd/yyyy) Dates: _____________
Hospice	No □	Yes □	If you answered yes, please provide dates of your stay(s) (mm/dd/yyyy to mm/dd/yyyy) Dates: _____________
In the past year, did you seek care at the Emergency Room?	No □	Yes □	If you answered yes, please provide dates of your visit(s) (mm/dd/yyyy) Dates: ___________
In the past year, did you take any antibiotics (drugs for infections, such as Amoxicillin, Bactrim or Keflex)?	No □	Yes □	If you answered yes, please provide medication and dates of use (mm/dd/yyyy to mm/dd/yyyy) Med: _______________ Dates: ______________ Med: _______________ Dates: ______________ Med: _______________ Dates: ______________ Med: _______________ Dates: ______________
In the past year, did you have any outpatient procedures? If yes, check all that apply: Endoscopy (a procedure to look at your stomach) Colonoscopy (a procedure to look in the colon for colorectal cancer) Interventional radiology procedure Add other, such as joint procedure, etc Specify________	No □ □ □ □	Yes □ □ □ □	If you answered yes, please give month and year of each outpatient procedure (mm/yyyy) Date: ____________ Date: ____________ Date: ____________ Date: ____________
Have you ever had a MRSA infection?	No □	Yes □	If yes, what type of infection was it? Skin? Blood? Other? ____________ please specify.

Please check or fill in the answer.
In the past year, how many outpatient medical visits did you have?	□ zero □ 1-2 □ 3-4 □ 5-8 □ 9-12 □ more than 13
In what year were you born?	|__|__|__|__| YYYY
What is your gender?	□ Male □ Female
Are you Spanish/Hispanic/Latino?	□ No □ Yes, Mexican, Mexican Am., Chicano □ Yes, Puerto Rican □ Yes, Cuban □ Yes, other Spanish/Hispanic/Latino
What is your race? (MARK ONE OR MORE RACES)	□ Asian □ American Indian or Alaska Native □ Black or African American □ Native Hawaiian or Other Pacific Islander □ White
What is your zip code?	|__|__|__|__|__|
How many people live in your household (including yourself)?	|__|__|

THANK YOU for completing this survey. Please return to us in the stamped, self- addressed envelope provided with this survey.