Pre-discussion Information Survey for Consumers (Self-de

Antibiotic Use Campaign – Pre-Discussion Information Survey (PDIS)

Self-Demander and Self-Expector 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. What is your highest education level completed? (Check only one)

• 11th grade or less

• 12th grade without a high school diploma

• 12th grade with a high school diploma

• GED

• Some college or technical school (1–3 years)

• Associate degree

• Completed college (4-year degree)

• Graduate or professional degree (Master’s degree or higher)

• Refused/unknown

5. What is your current employment status? (Check only one)

• Full-time employment for wages

• Part-time employment for wages

• Self-employed for wages

• Presently not employed outside the home, looking for work

• Presently not employed outside the home, not looking for work

• Unable to work

• Refused/unknown

6. What do you do for a living? (What is your occupation/profession?) _______________________

7. Where do you go most often for health care when you are sick? (Check all that apply)

• Doctor’s office

• Health department

• Clinic or health care center

• Senior community center

• Retail clinic (e.g. Walgreens Healthcare Clinics, CVS Minute Clinics, Target Clinic, Walmart Care Clinics, etc.)

• Hospital

• Emergency room

• Urgent care center

• Some other place (please specify ____________________)

• Don’t know

8. What type of healthcare professional do you typically seek general health advice from?

• Doctor

• Physician’s assistant or nurse practitioner

• Nurse

• Pharmacist

• Community health worker

• Other (Specify): __________________

• Don’t know

9. Please indicate below from which of the following sources you get information about antibiotics?

• Television

• Radio

• Newspaper

• Magazines

• Internet

• Mobile apps

• Doctor visits

• Pharmacist

• Church or religious organization

• Friends

• Family

• Other _________________

• Don’t know

10. Please indicate whether you believe each statement is true or false.

Statement	True	False
Antibiotics kill viruses.
Antibiotics are used to treat cold and flu.
Unnecessary use of antibiotics makes them less effective.
Antibiotics can have serious side effects.

11. Please answer the following items.

    Question	Yes	No	DK
    Have you ever taken an antibiotic you saved without consulting a healthcare professional?
    Have you ever taken an antibiotic that was prescribed for someone else without consulting a healthcare professional?
    Have you ever given someone else an antibiotic that was prescribed for you? If yes, who did you give the antibiotic to? ____________
    [Self expectors ONLY] Have you ever purchased an antibiotic over the counter without a prescription?
    Has a healthcare professional or pharmacist ever warned you about the side effects of taking antibiotics?
    Have you or someone you know ever experienced a serious side effect from taking an antibiotic?
    Have you or someone you know ever been diagnosed with an antibiotic-resistant infection?

12. When your healthcare professional prescribes an antibiotic, how confident are you that the antibiotic will make you feel better?

• Not at all confident

• Somewhat confident

• Confident

• Very confident

• Don’t know

13. When your healthcare professional prescribes an antibiotic, how often do you ask questions about appropriate antibiotic use?

• Never

• Rarely

• Sometimes

• Usually

• Always

• Don’t know

Thank you for completing this questionnaire.

AU Consumer Self-Demander and Self-Expector PDIS 3