Professional - Brief Survey

Form Approved

OMB No. 0920-0572

Expiration Date 03/31/2018

Submission under

0920-0572 Health Message Testing System

Attachment 8: Professional Brief Survey Instrument

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: OMB-PRA (0920-0572)

Information Needs

1. Would you be interested in receiving information about…

Topic	Yes	No
a. Communicating about reducing transmission
b. Communicating about ART
c. Communicating about nPEP
d. Communicating about PrEP
e. Communicating about ART medication adherence (e.g., patient compliance)
f. Communicating about STD screening
g. Partner services
h. Screening for risky sexual behaviors
i. Screening for risky alcohol and illicit drug use behaviors
j. Helping [INSERT POPULATION HERE] modify risky sexual behaviors
k. Helping [INSERT POPULATION HERE] modify alcohol and illicit drug use

Use of Electronic Media

2. 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 mobile device or tablet, such as an iPod/iPad
b. Download content to a mobile device, such as an iPod, cell phone, or PDA
c. Print online content such as a [trade] journal article
d. Access blogs
e. Use social media, like Twitter or Facebook
f. Listen to podcasts

[INSERT POPULATION HERE] resources

3. Do you refer your [INSERT POPULATION HERE] to the following resources…

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

4. Would you be interested in continuing education courses or programs about the following topics?

Topic	Yes	No
a. Communicating about reducing transmission
b. Communicating about ART
c. Communicating about nPEP
d. Communicating about PrEP
e. Communicating about ART medication adherence (e.g., patient compliance)
f. Communicating about STD screening
g. Partner services
h. Screening for risky sexual behaviors
i. Screening for risky alcohol and illicit drug use behaviors
j. Helping [INSERT POPULATION HERE] modify risky sexual behaviors
k. Helping [INSERT POPULATION HERE] modify alcohol and illicit drug use

4a. Of the CME courses or programs that you are interested in, please indicate your top three choices:

1. ______________________________________

2.______________________________________

3. _____________________________________

Communicating with [INSERT POPULATION HERE] about Risk Behaviors

5. What challenges, if any, prevent you from having discussions regarding high-risk sexual or substance use behaviors with your [INSERT POPULATION HERE]? [MARK ALL THAT APPLY]

a. Lack of time
b. Cultural difference between you and your [INSERT POPULATION HERE]
c. Gender difference between you and your [INSERT POPULATION HERE]
d. Lack of trust/relationship with [INSERT POPULATION HERE]
e. Lack of skills or training in this area
f. [INSERT POPULATION HERE] 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