Paper and Pencil Survey

Form Approved

OMB No. 0920-0840

Expiration Date 02/29/2016

Attachment 2
Paper-and-Pencil Survey

Formative Research to Develop Social Marketing Campaigns: Prevention Is Care (PIC)

Public reporting burden of this collection of information is estimated to average 15 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 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 CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0840).

PIC

Paper and Pencil Questionnaire

We recognize that many physicians split their time between private practices (individual or group) and practices that are public or university based. For the following question, please provide responses for both these practice types as applicable to your own practice of medicine. Please use your best estimate.

		Private Practice	Public or University Based Practice
Number of patients you see in a month.		______	______
2. Number of HIV-infected patients you see in a month.		______	______
		Male	Female
3. What percent of your patients are male vs. female? (Please use your best estimate)		________	__________

4. Which medical associations do you belong to? Please select one or more of the following associations. [MARK ALL THAT APPLY]

American Academy of Family Physicians (AAFP)

American College of Physicians (ACP)

American Medical Association (AMA)

National Medical Association (NMA)

HIV Medicine Association (HIVMA)

American Academy of HIV Medicine (AAHIVM)

Infectious Diseases Society of America (IDSA)

American Congress of Obstetricians and Gynecologists (ACOG)

International AIDS Society (IAS)

American College of Physicians (ACP)

Other [Specify:_________________]

None of these

Information Needs

5. Would you be interested in receiving information about…

Topic	Yes	No
a. Reducing transmission
b. Retention in care
c. Initiating ART
d. Communicating about ART medication adherence (e.g., patient compliance)
e. Conducting STD screening
f. Partner services
g. Screening for risky sexual behaviors
h. Screening for risky alcohol and illicit drug use behaviors
i. Helping patients modify risky sexual behaviors
j. Helping patients modify alcohol and illicit drug use

Use of Electronic Media

6. How often do you do the following for professional purposes?

	Daily	Weekly	Monthly	Less than once per month	Never
a. Use an app on a portable device, such as an iPod/iPad
b. Download content to a portable device, such as an iPod, cell phone, or PDA
c. Print online content such as a medical journal article
d. Access Medical blogs, such as those available through Medscape or Sermo
e. Use social media, like Twitter or Facebook
f. Listen to podcasts

Patient resources

7. Do you refer your patients to the following resources…

	Yes	No
a. Your practice’s website
b. CDC’s website
c. Other websites
d. Other electronic resources (specify)_______________________
e. Printed materials
f. Other (specify)_______________________________________

Continuing Medical Education (CME)

8. How do you obtain CME credits?

a. Attending conferences
b. Through employer-provided in-service trainings
c. Dinner presentations by local chapter of a professional association
d. Attending meetings of a regional professional association
e. Journal supplement education programs
f. Other (specify) ______________________________________

9. How useful are CME programs about HIV care, treatment and prevention?

a. Never useful
b. Rarely useful
c. Somewhat useful
d. Always useful

10. Do you currently use CME courses or programs as a source of information about the following topics?

Topic	Yes	No
a. Reducing transmission
b. Retention in care
c. Initiating ART
d. Communicating about ART medication adherence (e.g., patient compliance)
e. Conducting STD screening
f. Partner services
g. Screening for risky sexual behaviors
h. Screening for risky alcohol and illicit drug use behaviors
i. Helping patients modify risky sexual behaviors
j. Helping patients modify alcohol and illicit drug use

11. Would you be interested in CME courses or programs about the following topics?

Topic	Yes	No
a. Reducing transmission
b. Retention in care
c. Initiating ART
d. Communicating about ART medication adherence (e.g., patient compliance)
e. Conducting STD screening
f. Partner services
g. Screening for risky sexual behaviors
h. Screening for risky alcohol and illicit drug use behaviors
i. Helping patients modify risky sexual behaviors
j. Helping patients modify alcohol and illicit drug use

11A. Of the CME courses or programs that you are interested in, please indicate your top three choices:

1. ______________________________________

2.______________________________________

3. _____________________________________

Communicating with Patients about Risk Behaviors

12. What challenges, if any, prevent you from having discussions regarding high-risk sexual or substance use behaviors with your HIV-infected patients? [MARK ALL THAT APPLY]

a. Lack of time
b. Cultural difference between you and your patient
c. Gender difference between you and your patient
d. Lack of trust/relationship with patient
e. Lack of skills or training in this area
f. Patients are uncomfortable discussing the subject
g. I am uncomfortable discussing the subject
h. Other (specify) ______________________________
i. There are no challenges to such discussion that I can identify