Form #7 Form #7 Nurse Pre/Post Implementation Questionnaire

The Study of the Use of Nursing Home Antibiograms

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

1.

What is your title? (RN/LPN)

2.

What is your position at the facility?

3.

How long have you been in practice?

4.

How long have you been working at this facility?

5.

When you contact a physician regarding a resident with a suspected infection, what information do you convey? Please list.

6.

How is this information communicated to the physician? On a scale of 1 to 5 with 5 being most often and 1 least often, please circle the most appropriate number to indicate how frequently each method is used.

a.

Telephone

1 2 3 4 5

b.

Fax

1 2 3 4 5

c.

Email

1 2 3 4 5

d.

Face-to-face conversation

1 2 3 4 5

e.

Other – please list

1 2 3 4 5

7.

Are you familiar with antibiograms?

 Yes

 No

 Not sure

8.

Have you used antibiograms in this facility?

 Yes

 No

 Not sure

9.

Have you used antibiograms in another nursing home or other setting (e.g., hospital, home care)?

 Yes

 No

 Not sure

IF RESPONSE TO QUESTION 8 OR QUESTION 9 IS YES, PLEASE CONTINUE. IF NO, SURVEY IS COMPLETE. THANK YOU FOR TAKING THE TIME TO PARTIPATE IN THIS SURVEY.

10.

If you are currently using antibiograms or have used them in the past at this nursing home or at another setting, how was this information communicated to the physicians? More than one response may be selected.

 Fax

 Other (please list)

 Email

 Don’t know

 Mail

 They were not communicated

 Posted at the facility

11.

If you are currently using antibiograms or have used them in the past at this nursing home or at another setting, were physicians willing to use the information?

 Yes, Definitely

 Yes, Generally

 No, Generally

 No, Definitely

Public reporting burden for this collection of information is estimated to average 5 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.

Abt Associates Inc. 8