HCP Interview Sepsis

Pre Discussion Information Sheet

HCP Sepsis Interviews

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, not Hispanic or Latino

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

• American Indian or Alaska Native (Terminate at end)

• Asian (Terminate at end)

• Black or African American

• Native Hawaiian or Other Pacific Islander (Terminate at end)

• White (Terminate at end)

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 is your total household income from all sources?

• $0–$24,999

• $25,000–$49,999

• $50,000–$74,999

• $75,000–$99,999

• $100,000 or more

• Refused/unknown

7. Please identify your HCP role:

• Primary care physician

• Physician assistant

• Nurse practitioner

• Emergency department triage nurse

• General medical ward staff

• Nursing home staff

• Home healthcare provider

• Other (specify):

• Refused/unknown

8. Please indicate below from which of the following sources you would like to get information to help you educate patients about infections that lead to sepsis (check all that apply):

• HCPs (colleagues)

• Newspapers

• Magazines

• Medical journals

• Conferences/Lectures

• Medical webinars

• Internet

• Mobile apps

• Other (specify):

• Refused/Unknown

9. Please indicate below from which of the following sources you would like to get information to help you educate patients about sepsis in general (check all that apply):

• HCPs (colleagues)

• Newspapers

• Magazines

• Medical journals

• Conferences/Lectures

• Medical webinars

• Internet

• Mobile apps

• Other (specify):

• Refused/Unknown

10. Please indicate below from which of the following sources you would like to get information on rapid recognition/diagnosis of sepsis in patients (check all that apply):

• HCPs (colleagues)

• Newspapers

• Magazines

• Medical journals

• Conferences/Lectures

• Medical webinars

• Internet

• Mobile apps

• Other (specify):

• Refused/Unknown

Thank you for completing this questionnaire.

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