Pre-discussion Information Survey for Consumers (Caregiv

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

Caregiver-Demander and Caregiver-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

• Refused/unknown

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

• White

• Black or African American

• Asian

• American Indian or Alaska Native

• Native Hawaiian or Other Pacific Islander

• Refused/unknown

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. [Caregiver Demander] Do you have at least one child 5 years old or younger? ______

• Yes

• No

[Caregiver Expector] Are you a first-time parent to a child 2 years old or younger?

• Yes

• No

8. Where do you go most often for health care when you/your child is 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 MinuteClinics, Target Clinic, Walmart Care Clinics, etc.)

• Hospital

• Emergency room

• Urgent care center

• Some other place (please specify ____________________)

• Don’t know

9. 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

10. 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 _________________

• Refused/Unknown

11. 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.

12. Please answer the following items.

    	Yes	No	DK
    Have you ever given your child an antibiotic you saved without consulting a healthcare professional?
    Have you ever given your child 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 your child? If yes, who did you give the antibiotic to? ____________
    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?

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

• Not at all confident

• Somewhat confident

• Confident

• Very confident

• Don’t know

14. 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 Caregiver-Demander and Caregiver-Expector PDIS 3