Form 0920-0879 Attachment B- SBRL Instrument - Word Version

Attachment B: Information Collection Instrument (Word Version)

Online assessment questions (Assessment to be created in Epi Info)

Form Approved

OMB No. 0920-0879

Expiration Date 03/31/2018

Instructions

Welcome! This data collection is meant for state public health laboratory officials acting in their official capacities and aims to estimate the annual burden of Nocardia related diseases in the United States, and assess level of state use of CDC’s SBRL services. We are asking laboratory managers from all 50 states and the District of Columbia to participate in this assessment.

Your feedback is important to us and will allow us to assess the burden of Nocardia related illnesses, help us to understand your laboratories current species and antibiotic resistance testing procedures, and determine how CDC’s Special Bacteriology Reference Laboratory can better serve your needs.

Completing the questionnaire is voluntary and takes approximately 10 minutes. CDC will not publish or share any identifying information about individual respondents with CDC. There are no known risks or direct benefits to you from participating or choosing not to participate, but your answers will help CDC improve estimates of the annual burden of Nocardia related diseases in the United States.

If you have any questions or concerns about this assessment, please contact Shannon Cooney at [email protected]

To begin, please click begin survey below.

CDC estimates the average public reporting burden for this collection of information as 10 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0879).

Respondent Information

1. Which state health department do you represent? ____________________

2. What is your position with this organization? _________________________

Nocardia identification testing

3. Does your lab have the ability to identify Nocardia samples sent to you from medical facilities in your state? (if no, skip to next page)

____ Yes

____ No

4. Approximately how many Nocardia samples did your lab identify in 2015?

____ <20

____ 20-50

____ >50

5. How has the number of Nocardia samples your lab identified changed over the past 5 years?

____ Increased

____ Decreased

____ No change

6. What are the most common Nocardia species that your lab has isolated in the past year? (check up to 5)

____ N. abscessus

____ N. arthritidis

____ N. asteroides

____ N. beijingensis

____ N. brasiliensis

____ N. brevicatena

____ N. cyriacigeorgica

____ N. farcinica

____ N. nova

____ N. otitidiscaviarum

____ N. veteran

Other: ___________________

7. What technologies does your lab use to identify Nocardia species? (check all that apply)

____ MicrobeNet

____ Phenotypic (Biochem/morphological)

____ AST

____ 16S/ gyrB sequencing

____ Don’t know

____ Other: _____________________________________

Nocardia susceptibility testing

8. Approximately, what percentage of Nocardia isolates that your lab received in 2015 did the submitter (medical facility, physician) request that you perform susceptibility testing for?

____ 0-25%

____ 26-50%

____ 51-75%

____ 76-100%

____ N/A

9. Does your lab perform antibiotic susceptibility testing on Nocardia isolates? (If no, skip to next page)

____ Yes

Approximately, what percentage of Nocardia isolates that your lab received in the past year did you perform susceptibility testing for?

____ 0-25%

____ 26-50%

____ 51-75%

____ 76-100%

____ No

10. Which method(s) of susceptibility testing does your lab use for Nocardia?

____ Disc diffusion

____ E-test

____ Broth microdilution

____ Don’t know

____ Other: _____________________________________

CDC SBRL testing

11. a. Are you aware that CDC’s Special Bacterial Reference Laboratory (SBRL) offers species testing for all aerobic actinomycetes? (This service is free of charge)

____ Yes

____ No

2. Are you aware that CDC’s Special Bacterial Reference Laboratory (SBRL) offers susceptibility testing for all aerobic actinomycetes? (This service is free of charge)

____ Yes

____ No

12. Did your lab send any Nocardia samples to CDC for identification or susceptibility testing in 2015?

____ Yes, for identification testing only

Approximately how many samples in the past year? (skip to 14)

____ 0-20

____ 20-50

____ 50+

____ Yes, for susceptibility testing only

Approximately how many samples in the past year? (skip to 14)

____ 0-20

____ 20-50

____ 50+

____ Yes, for both identification and susceptibility testing

Approximately how many samples in the past year? (skip to 14)

Identification testing

____ 0-20

____ 20-50

____ 50+

Susceptibility testing

____ 0-20

____ 20-50

____ 50+

____ No (skip to 13)

13. If your lab did not send any Nocardia or Actinomycetes samples to CDC for testing in 2015, please check the reason(s) below.

____ Response/ turnaround time is insufficient

____ Shipping costs

____ Species level identification was not necessary

____ Susceptibility testing was not necessary

____ State laboratory could perform all of the needed testing

____ Not aware that CDC offers this service

____ Other: ________________________________

14. Are you aware that CDC’s SBRL offers training in 16S sequence analysis to assist with species identification?

____ Yes

____ No

15. Are you familiar with the online resource MicrobeNet?

____ Yes

____ No (skips to 16)

15b. Does your lab use the MicrobeNet search functions for assistance in identifying Nocardia?

____ Yes

____ No

Comments

16. Do you have any suggestions for how SBRL can better provide services to you?

Comments: ______________________________________________________________

17. Would your organization be willing to work with SBRL to provide further information for an annual summary of aerobic actinomycetes? If so, please provide contact information for your laboratory in the comment section below.

Optional: ______________________________________________________________

Thank you for your participation in this assessment!