Educating Groups Influencing Generic Drug Use

Appendix G: Survey Instrument – Prescribers

OMB No. 0910-0695
Expiration Date: 02-28-2021

Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is
not required to respond to a collection of information unless it displays a valid OMB control number. The
valid OMB control number for this information collection is 0910-0695 and the expiration date is 2/28/2021.
The time required to complete this information collection is estimated to average 20 minutes per response,
including the time for reviewing instructions and completing and reviewing the collection of information.

Prescriber Survey
(NOTE: DO NOT AGREE TO PARTICIPATE UNLESS AN IRB APPROVAL STAMP WITH
CURRENT DATES HAS BEEN APPLIED TO THIS DOCUMENT.)

Informed Consent for a research study entitled: “Educating Groups Influencing
Generic Drug Use”
You are invited to participate in a research study to better educate groups influencing
generic drug use, based on their unique educational needs, sponsored by the US Food
and Drug Administration (FDA). The study is being conducted by Dr. Jingjing Qian,
Assistant Professor in the Auburn University Department of Health Outcomes Research
and Policy and Dr. Ilene Harris, Principal Research Scientist at IMPAQ International.
You are eligible to participate if you are a healthcare provider with US prescriptive
authority and are age 19 or older.
As part of your participation in this research study, you will fill out an online survey
regarding your review of the developed educational materials. Your total time
commitment will be approximately 20 minutes.
The risks associated with participating in this study are minimal. Your protected
health information will not be used or disclosed to a third party. If you participate in this
study, what the research team learns from your survey may better inform whether the
developed educational materials are successful in educating various groups on
generic drugs. You will receive $50 as a token of our appreciation for your
participation after completion of the survey.
If you change your mind about participating, you can withdraw at any time during
the study. Your participation is completely voluntary. If you choose to withdraw, your
data can be withdrawn as long as it is identifiable. Your decision about whether or not
to participate or to stop participating will not jeopardize your future relations with Auburn
University, the Department of Health Outcomes Research and Policy, or IMPAQ
International.
If you agree, any data obtained in connection with this study will be anonymous. Notes
and complete surveys will be saved in password protected folders on a password and
firewall protected server at Auburn University.
Information collected through your participation may be published in governmental
reports, professional journals, and/or presented at a professional meeting. As described
above, surveys will have no identifying information attached to them, and if information
learned from this study is published, you will not be identified by name or other personal
information. Also, survey answers will be used for analytical purposes only.
If required, personal information collected in connection to your honorarium will be
saved in password protected folders on a password and firewall protected server at
Auburn University. This information is being collected in order to withhold necessary
tax payments on your behalf and will remain private to the extent permitted by law.

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Appendix G: Survey Instrument – Prescribers

If you have questions about this study, please contact Jingjing Qian at (334)
844-5818 or [email protected] or Ilene Harris at (443) 259-5250 or
[email protected].
If you have questions about your rights as a research participant, you may contact the
Auburn University Office of Research Compliance or the Institutional Review Board by
phone at (334) 844-5966 or e-mail at [email protected] or
[email protected].
HAVING READ THE INFORMATION PROVIDED, YOU MUST DECIDE WHETHER OR NOT
YOU WISH TO PARTICIPATE IN THIS RESEARCH STUDY. IF YOU AGREE TO
PARTICIPATE, PLEASE PRESS 'YES' BELOW.
Do you agree to participate in this survey?
 Yes
 No
If No, then END SURVEY.

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Appendix G: Survey Instrument – Prescribers
1. Are you at least 19 years of age?
 Yes
 No
If No, then END SURVEY.

2. Are you a physician, nurse practitioner, or physician's assistant with prescriptive authority in
the U.S.?
 Yes
 No
If No, then END SURVEY.

3. Are you actively involved in patient care at least 2 days per week?
 Yes
 No
If No, then END SURVEY.

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Appendix G: Survey Instrument – Prescribers
Thank you for agreeing to participate in this survey! Your thoughtful responses are
important to us. Please press 'NEXT' to continue.

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Appendix G: Survey Instrument – Prescribers
Now we will show you an example of an educational material about generic drugs that we
designed for prescribers. On the next screen, please read the educational material and
answer the questions that follow. Please press 'NEXT' to continue.

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Appendix G: Survey Instrument – Prescribers
Please take a few minutes to read over this newsletter. After you've looked it over, we
will ask you to answer a few questions about your opinion of its content, format, and
delivery.

EDUCATIONAL MATERIAL INSERTED HERE

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Appendix G: Survey Instrument – Prescribers
The questions on the next screen ask about your thoughts on the newsletter's CONTENT.
Please press 'NEXT' to continue.

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Appendix G: Survey Instrument – Prescribers
4. On a scale of 1 to 5, where 1=Strongly Disagree and 5=Strongly Agree, please indicate how
much you agree or disagree with each statement. The newsletter...
Strongly
Disagree
1

Disagree
2

Neither
Agree nor
Disagree
3

Agree
4

Strongly
Agree
5

Gave adequate
information about
generic drug
safety and
efficacy











Gave adequate
information about
FDA approval
processes for
generic drugs











Gave adequate
information about
generic drug
access and cost











Gave useful
information on
resources for
generic drug
availability and
cost











Gave just the right
amount of
information about
generic drugs











Gave unbiased
information











Gave information
that was
interesting to me











Gave information
that was new to
me











Gave information
that will help me
better serve
patients











Gave information
that I agree with











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Appendix G: Survey Instrument – Prescribers
5. On a scale of 1 to 5, where 1=Not at all Satisfied and 5=Very Satisfied, how satisfied were
you with the newsletter's content?






Not at all Satisfied=1
Slightly Satisfied=2
Fairly Satisfied=3
Satisfied=4
Very Satisfied=5

6. Please provide any comments about the newsletter's CONTENT.

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Appendix G: Survey Instrument – Prescribers
The questions on the next screen ask about your thoughts on the newsletter's
FORMAT. Please press 'NEXT' to continue.

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Appendix G: Survey Instrument – Prescribers
7. On a scale of 1 to 5, where 1=Strongly Disagree and 5=Strongly Agree, please indicate how
much you agree or disagree with each statement. The newsletter...
Strongly
Disagree
1

Disagree
2

Neither
Agree nor
Disagree
3

Agree
4

Strongly
Agree
5

Was easy to read











Was easy to
understand











Had a layout that
made sense











Had just the right
amount of text











Was visually
appealing











Was well
organized











Was just the right
length











Was easy to see











Loaded easily on
my computer or
phone











Had a format that
was easy for me
to use











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Appendix G: Survey Instrument – Prescribers
8. On a scale of 1 to 5, where 1=Not at all Satisfied and 5=Very Satisfied, how satisfied were
you with the newsletter's format?






Not at all Satisfied=1
Slightly Satisfied=2
Fairly Satisfied=3
Satisfied=4
Very Satisfied=5

9. Please provide any comments about the newsletter's FORMAT.

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Appendix G: Survey Instrument – Prescribers
The questions on the next screen ask about your thoughts on the newsletter's
DELIVERY. Please press 'NEXT' to continue.

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Appendix G: Survey Instrument – Prescribers
10. From whom would you most prefer to receive a newsletter with information about generic
drugs?







Food and Drug Administration (FDA)
Professional association
Prescription insurance company
Pharmaceutical company
Employer
Other, please specify ____________________

11. How would you most prefer to receive a newsletter about generic drugs?






Email
Online website
Mobile app
Mail
Other, please specify ____________________

12. Please provide any comments about the newsletter's DELIVERY.

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Appendix G: Survey Instrument – Prescribers
The questions on the next screen ask about your OVERALL SATISFACTION with the
newsletter. Please press 'NEXT' to continue.

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Appendix G: Survey Instrument – Prescribers
13. On a scale of 1 to 5, where 1=Not at all and 5=Completely, please indicate your opinion for
each statement.
Not at all
1

Slightly
2

Somewhat
3

A lot
4

Completely
5

How satisfied are
you with the
quality of the
newsletter?











How interesting
and engaging
was the
newsletter?











How necessary
does this type of
newsletter seem?











How confident
are you that the
newsletter will
help you in
practice?











How confident
would you be in
recommending
this newsletter to
other
prescribers?











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Appendix G: Survey Instrument – Prescribers
14. What did you LIKE MOST about the newsletter?

15. What did you LIKE LEAST about the newsletter?

16. Please provide any comments about HOW TO IMPROVE the newsletter for prescribers.

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Appendix G: Survey Instrument – Prescribers
Next, please tell us a bit about yourself. Please press 'NEXT' to continue.

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Appendix G: Survey Instrument – Prescribers
17. What is your age?

18. What is your gender?
 Male
 Female

19. What is your race?
 Caucasian/White
 Black or African American
 Asian
 Native Hawaiian or Other Pacific Islander
 Native American or Alaska Native
 Two or more races

20. What is your ethnicity?
 Hispanic or Latino(a)
 Not Hispanic or Latino(a)

21. What is your medical specialty? Please mark all that apply.
 Family Medicine
 Internal Medicine
 Geriatrics
 Pediatrics
 OB/GYN
 Hematology/Oncology
 Psychiatry
 Radiology
 Cardiology
 Endocrinology
 Neurology
 Pulmonology
 Other, please specify ____________________

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Appendix G: Survey Instrument – Prescribers
22. Please indicate which of the following most accurately describes your PRIMARY practice
setting?
 Solo Private Practice
 Single-specialty Group or Partnership
 Multi-specialty Group or Partnership
 Hospital Outpatient
 Hospital Emergency Department
 Multi-Hospital System
 Urgent Care Center
 Academic Medical Center
 Cancer Center
 Mental Health Center
 Federally Qualified Health Center
 Other, please specify ____________________

23. Do you practice in more than one setting?
 Yes
 No

Display This Question:
If Do you practice in more than one setting?  Yes Is Selected
24. Please select all other practice settings you work in.
 Solo Private Practice
 Single-specialty Group or Partnership
 Multi-specialty Group or Partnership
 Hospital Outpatient
 Hospital Emergency Department
 Multi-Hospital System
 Urgent Care Center
 Academic Medical Center
 Cancer Center
 Mental Health Center
 Federally Qualified Health Center
 Other, please specify ____________________

25. How would you describe the area/community that you primarily practice in?
 Rural
 Suburban
 Urban

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Appendix G: Survey Instrument – Prescribers
26. Which of the following best describes the size of your practice setting?
 Solo
 Small (2-10 physicians)
 Medium (11-50 physicians)
 Large (51 or more physicians)

27. How many years have you been practicing as a healthcare provider?

28. What is your medical degree?
 MD
 DO
 PA
 CNP
 Other, please specify ____________________

29. Are you board certified in your primary area of practice?
 Yes, please list certifications ____________________
 No

30. Please indicate the average number of patients you see per week.

31. Please indicate what percentage of your patient population reflects the following categories.
0-25%

26-50%

51-75%

76-100%

Children









Women









Medicare
Beneficiaries









Medicaid
Beneficiaries









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Appendix G: Survey Instrument – Prescribers
Thank you for taking the time to fill out this survey! Please press 'NEXT' to record your
responses.

27

Appendix G: Survey Collection Form – Honorarium
Contact Information for Survey Honorarium
If you provide your contact information, you will have the opportunity to receive a $50 as
a token of our appreciation for your participation. Would you like to provide your
contact information?

What is your first name?

What is your last name (family name)?

What is your Auburn University Banner ID (for faculty or staff)?

What is your mailing address?

What is your daytime telephone number?

What is your email address?