Pre-Discussion Information Survey for Health Care Profes

Antibiotic Use Campaign—R2 Concept Testing

Pre-Discussion Information Survey (PDIS) – HCP Version

Please provide some information about yourself by completing this questionnaire. We will not report any of your responses by name. Thank you.

1. What is your age? _____

2. Would you describe yourself as Hispanic or Latino?

• Yes

• No

3. How would you describe your racial background? Please check all that apply.

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or Other Pacific Islander

• White

4. Please identify your HCP role.

   • Nurse practitioner

   • Physician’s assistant

   • Family practitioner

   • Emergency department attending physician

   • Urgent care owner-physician

   • Hospitalist (specify specialty) _________________________________

   • Other (please specify): _________________________

   • Don’t know

5. Please indicate below from which of the following sources you would like to get information to help educate your patients about appropriate antibiotic use:

• Medical journals

• Conferences/Lectures

• Medical webinars

• Email

• Social media (Facebook, Twitter)

• Websites

• Professional societies

• Mobile apps

• Other (specify): ____________________________________________

• Don’t know

6. On a typical day, how often do you:

   	Never	Rarely	Sometimes	Usually	Always
   Talk to your patients about antibiotic resistance
   Talk to your patients about adverse drug events associated with antibiotic use
   Talk to your patients about appropriate antibiotic use

7. What resources, if any, do you refer patients to about appropriate antibiotic use?

   • Posters

   • Brochures

   • Palm Cards

   • Videos

   • Mobile Apps

   • Websites (please specify ______________________)

   • Other (please describe ______________________)

   • Other (please describe ______________________)

   • Don’t know

8. What additional types of resources on appropriate antibiotic use would be helpful for patients?

• Posters

• Brochures

• Palm Cards

• Doctor-patient discussion guides

• Videos

• Mobile Apps

• Websites (please specify ______________________)

• Other (please describe ______________________)

• Don’t know

1. What resources, if any, do you personally refer to when prescribing antibiotics?

   • Checklists

   • Information in an electronic health record

   • Pocket reference guide

   • Mobile Apps (please specify ______________________)

   • Websites (please specify ______________________)

   • Other (please describe ______________________)

   • Don’t know

10. What additional types of resources on appropriate antibiotic prescribing would be helpful for you as a healthcare professional?

    • Checklists

    • Information in an electronic health record

    • Mobile Apps

    • Pocket reference guide

    • Website

    • Other (please describe ______________________)

    • Don’t know

Thank you for completing this questionnaire.

HCP PDIS 2

051517