Pretest Instrument Word version

Get Ahead of Sepsis Consumer Survey (GAOSCS) Form Approved

OMB Control No.: 0920-0572

Expiration Date 08/31/2021

Survey Section by Test Segment:

Survey Section	Pretest (n=30/TA)	Posttest
		Exposed (n = 30/TA)	Unexposed (n = 30/TA)	Unexposed (n = Unlimited)
Informed Consent	X	X	X	X
Screener	X	X	X	X
Exposure to Campaign	X	X	X	X
Frequency and Channel of Exposure	X	X
Knowledge	X	X
Attitudes & Beliefs	X	X
Behavior	X	X
Sources of Information	X	X
Media Use and Habits			X
Demographic Characteristics	X	X	X

Target Audiences:

• Healthy adults 65+

• Women who care for a child ≤ 12 years old

• Women who care for an older adult family member 65+

• Men 65+ with one or more chronic conditions

***************************************************

INFORMED CONSENT

Before beginning the survey, there are a few things you should know.

On behalf of the Centers for Disease Control and Prevention (CDC), the research firm ICF is conducting an online survey with adults from the community to gather feedback on educational materials related to sepsis. These materials were developed in partnership with the CDC, and we hope to use what we learn from these survey results to improve these materials and/or how and where we promote them to raise awareness within your community. We expect this survey to take about 20 minutes. You will only be asked to complete this survey once.

We want to learn from you, so we encourage you to answer honestly. There are no right or wrong answers. If you agree to participate in the survey, here are some points to know:

• Rights Regarding Participation: Your participation in this survey is completely voluntary. You may choose to leave the survey and/or not answer a question at any time for any reason. Refusal to participate will involve no penalty or loss of benefits.

• Privacy: We will take every precaution to protect your identity and ensure your privacy. We will keep your name and answers to these survey questions private. Your name and contact information will be kept separate from any survey responses. We will never use your name in any reports.

• Benefits: Your participation in the survey will not result in any direct benefits to you. However, your input will help us to develop and improve educational materials about sepsis for people like you.

• Risks: There is no known risk to you for your participation in the survey.

• Contact Information: If you have any questions about this survey or the campaign, please contact the research director, Kristen Cincotta, PhD, at 404-320-4433.

Do you agree to participate in the survey?  Yes  No

Programmer: If respondent selects yes, please proceed to the survey.
If respondent selects no, display termination text.

Termination text: “Thank you for your time. Click here [insert URL] to exit this survey.”

SCREENER

The results of this survey will help the Centers for Disease Control and Prevention (CDC) refine its ongoing campaign to improve antibiotic use by helping CDC staff understand the public’s response to the campaign and its key messages. You will be asked to complete different versions of the survey depending on whether you have seen or heard certain messages from the CDC about sepsis.

Programmer: Include one question per page.
Screener should terminate as soon as respondent selects an option that deems him/her ineligible.

1. May we ask you some questions to see if you are a good match to take this survey?

• Yes

• No [INELIGIBLE]

Programmer: If respondent selects “No,” TERMINATE.
If respondent selects “Yes,” proceed to Q2.

2. How old are you? _ _ years

• Prefer not to answer [INELIGIBLE]

Programmer: If 18+ years, proceed to Q3.
If under 18 years, TERMINATE.
If respondent selects “Prefer not to answer,” TERMINATE.

3. In what ZIP code do you live? ______

Programmer: If ZIP code is within the target areas, proceed to Q4.
If not within the target area, TERMINATE.

4. What is your sex?

• Male

• Female

• Other, please specify: __________

• Prefer not to answer

Programmer: If respondent selects “Male,” “Other, please specify,” or “Prefer not to answer,” skip to Q8.

If respondent selects “Female,” proceed to Q5.

5. Are you currently the primary caregiver for an older adult family member (age 65 years or older)?

• Yes

• No

Programmer: If respondent selects “Yes” to Q5 and is between 18-64 years of age, categorize respondent as “Women who care for an elderly adult 65+ years.”

If respondent selects “No,” proceed to Q6.

6. Are you the parent of at least one child who is 12 years old or younger?

• Yes

• No

Programmer: If respondent selects “No” to Q6, skip Q7.

7. Who in your family usually makes health care decisions about this child/these children?

• Self

• Self and spouse or partner together

• Someone else [INELIGIBLE for “Women who care for a child ≤ 12 years old” category]

Programmer: If respondent selects “Yes” to Q6, “Self” or “Self and spouse or partner together” to Q7, and is between 18-64 years of age, categorize respondent as “Women who care for a child 12 years or younger.”

If respondent selects “No” to Q6 or “Someone else” to Q7, proceed to Q8.

8. Has a healthcare professional ever diagnosed you with a chronic medical condition or disease?

• Yes

• No

• Do not know [INELIGIBLE]

Programmer:  If respondent selects “Yes” to Q8, proceed to Q9.

If respondent selects “No” to Q8 and is 65+ years of age, categorize respondent as “Healthy adults 65+.”

If respondent selects “Do not know,” TERMINATE.

9. Has a healthcare professional ever told you that you have one of the following chronic conditions or diseases?

• Arthritis

• Cancer

• Chronic Kidney Disease

• Chronic Obstructive Pulmonary Disease

• Diabetes

• Heart Disease

• Immunosuppression

• Stroke

• OTHER: __________ [INELIGIBLE]

• None of the above [INELIGIBLE]

Programmer:  If respondent selects “Other” or “None of the above,” TERMINATE.

If respondent selects “Arthritis,” “Cancer,” “Chronic Kidney Disease,” “Chronic Obstructive Pulmonary Disease,” “Diabetes,” “Heart Disease,” “Immunosuppression,” or “Stroke” to Q9 and is 65+ years of age, categorize respondent as “Men 65+ with one or more chronic conditions.”

Programmer:  Categorize respondent.

Categorize respondent as “Women who care for an elderly adult 65+ years”

• Q2 = 18-64

• Q4 = Female

• Q5 = Yes

Categorize respondent as “Women who care for a child ≤ 12 years”

• Q2 = 18-64

• Q4 = Female

• Q6 = Yes

• Q7 = Self or Self and spouse or partner together

Categorize respondent as “Healthy adults 65+”

• Q2 = 65+

• Q8 = No

Categorize respondent as “Men 65+ with one or more chronic conditions”

• Q2 = 65+

• Q4 = Male

• Q8 = Yes

• Q9 = Arthritis, Cancer, Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, Diabetes, Heart Disease, Immunosuppression, or Stroke

10. Do you, your spouse or partner, or any other member of your household currently or in the past work for/as:

	Yes	No
a. A market research company		
b. An advertising agency or public relations firm		
c. The media (TV/radio/newspapers/magazines)		
d. A healthcare setting or a health and wellness organization (e.g., doctor’s office, clinic, hospital, health department, fitness center)		
e. A healthcare professional (e.g., doctor, nurse, pharmacist, physician assistant, medical assistant, dietician, aid, sitter, social worker)		

Programmer: If respondent selects “Yes” any of the options for Q10, TERMINATE.
If respondent selects “No” for Q10, proceed with survey.

TERMINATION TEXT:  

Thank you for your willingness to participate and answer our questions. Unfortunately, you do not meet the criteria to continue with the survey. If you have any questions about your participation and/or any questions about this survey, please contact the research director, Kristen Cincotta, Ph.D., at (404) 321-3211 or [email protected]. Thank you for your time.

If ELIGIBLE, proceed with survey. 

Thank you for answering the questions. We have determined that you are a good match for this survey. If you have any questions about your participation and/or any questions about this survey, please contact the research director, Kristen Cincotta, Ph.D., at (404) 321-3211 or [email protected]. 

EXPOSURE TO CAMPAIGN

Programmer: Include one question per page

Now we would like to ask you about a CDC campaign to raise awareness about a medical condition called sepsis that you may or may not have seen or heard about in the past 12 months.

11. Please indicate below whether you have seen or heard any of following campaign names or slogans in the past 12 months.

    Campaigns	Yes	No	Do not know /cannot recall
    Health is Precious. Don’t Get Sepsis.			
    Be Sepsis Aware			
    Get Ahead of Sepsis			
    Be Smart. Beat Sepsis.			
    Know the Threat. Prevent Sepsis.			

12. I n the past 12 months, did you see this logo or hear the slogan on it anywhere?

• Yes

• No

• Do not know/cannot recall

Programmer:

TERMINATION TEXT if INELIGIBLE:  

“Thank you for your willingness to participate and answer our questions. Unfortunately, you do not meet the criteria to continue with the survey. If you have any questions about your participation and/or any questions about this survey, please contact the research director, Kristen Cincotta, Ph.D., at (404) 321-3211 or [email protected]. Thank you for your time.”

CLASSIFY: If respondent selects “Yes” for C for Q11 and/or “Yes” or “Do not know/cannot recall” for Q12, classify as “Exposed” and continue to Frequency and Channel of Exposure section.

If A, B, D, or E (but not C) are selected for Q11 and “No” for Q12, classify as “Unexposed” and continue to Knowledge section.

FREQUENCY AND CHANNEL OF EXPOSURE [PRE-TEST, EXPOSED ONLY]

Programmer: Include one question per page.

You indicated that you had seen or heard the campaign name, Get Ahead of Sepsis, or seen the campaign logo in the past 12 months.

13. In the past 12 months, approximately how often did you see CDC’s Get Ahead of Sepsis campaign messages, campaign name, or logo in …?

    PRINTED MEDIA	1-2 times a day	Once a week	1-3 times a month	Less than once a month	Never	Do not know/ cannot recall
    Poster						
    Fact sheet						
    Brochure						
    Graphic						
    Newspaper/magazine advertisement						
    Flyer						
    Other print media (please specify: _____________)						

14. In the past 12 months, approximately how often did you see CDC’s Get Ahead of Sepsis campaign messages, campaign name, or logo on …?

    SOCIAL MEDIA	1-2 times a day	Once a week	1-3 times a month	Less than once a month	Never	Do not know/ cannot recall
    Facebook						
    Instagram						
    Twitter						
    LinkedIn						
    YouTube						
    Other social media (please specify: _____________)						

15. In the past 12 months, approximately how often did you see CDC’s Get Ahead of Sepsis campaign messages, campaign name, or logo in …?

    ONLINE/INTERNET MEDIA	1-2 times a day	Once a week	1-3 times a month	Less than once a month	Never	Do not know/ cannot recall
    Health websites /resources						
    Website advertisements						
    Online news articles						
    Streaming TV/video services (e.g., Hulu, Netflix, [Amazon] Prime Video)						
    Blogs						
    Advertisements on mobile phone (including mobile apps)						
    Search engines (e.g., Google)						
    Other websites (please specify: _____________)						

16. In the past 12 months, approximately how often did you see CDC’s Get Ahead of Sepsis campaign messages, campaign name, or logo in …?

TV OR RADIO MEDIA	1-2 times a day	Once a week	1-3 times a month	Less than once a month	Never	Do not know/ cannot recall
Television (cable, satellite, or antenna)						
Broadcast radio						
Other media formats (please specify: _____________)						

17. In the past 12 months, approximately how often did you see CDC’s Get Ahead of Sepsis campaign messages, campaign name, or logo in …?

PUBLIC PLACES	1-2 times a day	Once a week	1-3 times a month	Less than once a month	Never	Do not know/ cannot recall
Billboards						
Bus, train, or subway stations						
On buses or taxi cabs						
Advertisement in a mall						
Advertisement in a grocery store						
Advertisement in a store pharmacy (e.g., CVS, Walgreens, Walmart)						
Other public locations (please specify: _____________)						

18. In the past 12 months, approximately how often did you see CDC’s Get Ahead of Sepsis campaign messages, campaign name, or logo in …?

HEALTHCARE SETTINGS	1-2 times a day	Once a week	1-3 times a month	Less than once a month	Never	Do not know/ cannot recall
Videos/commercials shown at doctor’s offices or healthcare facilities						
Other healthcare locations (please specify: _____________)						

19. In the past 12 months, approximately how often did you see CDC’s Get Ahead of Sepsis campaign messages, campaign name, or logo in …?

OTHER MEDIA	1-2 times a day	Once a week	1-3 times a month	Less than once a month	Never	Do not know/ cannot recall
Emails						
Email newsletters						
Webcasts or webinars						
Live events						
Other media (please specify: _____________)						

Programmer: PRE-TEST: If respondent selects “Never” or “Do not know/cannot recall” for ALL of the options in Q13-Q19, proceed to “Knowledge.” Reclassify these respondents as “Unexposed.”

PRE-TEST: If respondent selects “1-2 times a day,” “Once a week,” “1-3 times a month,” or “Less than once a month” for any of the options in Q13-19, proceed to “Knowledge.”

KNOWLEDGE

Programmer: Include one question per page

20. Sepsis is defined as the following:

• A chronic condition that mainly affects kidney function

• A blood infection

• The body’s extreme response to an infection

• A neurological disorder resulting from the flu

• Contagious illness that commonly peaks in the winter

• All of the above

• None of the above

• Do not know

21. Sepsis is a medical emergency.

□ TRUE

□ FALSE

22. Almost any infection can lead to sepsis.

• TRUE

• FALSE

23. Infections do not put you and your family at risk for a life-threatening condition called sepsis.

□ TRUE

□ FALSE

24. When germs get into a person’s body, they can cause an infection. If that infection isn’t stopped, it can cause sepsis.

□ TRUE

□ FALSE

25. The following are the most common types of infections that can lead to sepsis EXCEPT:

□ Skin

□ Lungs

□ Urinary tract

□ Ear

26. Which of the following groups of individuals are at high risk for developing infections than can lead to sepsis, and sepsis? (Select all that apply)

• Adults aged 65 and older

• Children or adults with chronic conditions like diabetes, lung disease, cancer, and kidney disease

• Children younger than 1 years old

• Children or adults with weakened immune systems

• Children or adults who have previously survived sepsis

• All of the above. Anyone can get an infection.

• Do not know

• None of the above

27. Check all the signs and symptoms of sepsis below:

• Excessive thirst

• Clammy or sweaty skin

• Confusion or disorientation

• Extreme pain or discomfort

• Fever, shivering, or feeling very cold

• High heart rate

• Shortness of breath

• I do not know any of the signs and symptoms of sepsis.

28. If you suspect sepsis or has an infection that’s not getting better or is getting worse, you should ask your doctor or nurse, “Could this infection be leading to sepsis?”

• TRUE

• FALSE

29. Which of the following activities, if any, can help prevent infections that can lead to sepsis? (Select all that apply)

• Washing your hands regularly

• Showering daily

• Getting recommended vaccines

• Avoiding public restrooms

• Keeping cuts and wounds covered and clean until healed

• Taking good care of chronic conditions

• All of the above

• None of the above

ATTITUDES AND BELIEFS

Programmer: Include one question per page. Do not allow participants to go back and change their answer to a previous question.

Programmer: Use the following section for Healthy adults 65+ and Men 65+ with one or more chronic conditions.

Next, we are going to ask you some questions to learn more about your perspective on infections and sepsis. Please give us your honest responses. There are no right or wrong answers to any of these questions.

We’d like to provide you with a definition for sepsis to assist you in answering the following questions:

Sepsis is the body’s extreme response to an infection. It is life-threatening, and without timely treatment, sepsis can rapidly lead to tissue damage, organ failure, and death.

Please indicate the extent to which you agree with the following statements, from strongly disagree to strongly agree.

[Perceived Susceptibility]	Strongly disagree	Disagree	Neutral	Agree	Strongly agree
I am at risk of developing infections that could lead to sepsis.					
I am at risk of developing sepsis.					
[Perceived Severity]	Strongly disagree	Disagree	Neutral	Agree	Strongly agree
If I developed sepsis, it could cause severe problems, such as tissue damage and organ failure.					
If I develope sepsis, it could lead to death.					
[Perceived Benefits]	Strongly disagree	Disagree	Neutral	Agree	Strongly agree
[Please show this to ONLY Men 65+ with one or more chronic conditions] If I take proper care of my chronic condition(s), this will decrease my chances of developing infections that can lead to sepsis.					
If I practice good hand hygiene, this will decrease my chances of developing infections that can lead to sepsis.					
If I keep my wounds clean and covered until healed, this will decrease my chances of developing infections that can lead to sepsis.					
If I get recommended vaccinations, this will decrease my chances of developing infections that can lead to sepsis.					
Fast recognition of the signs and symptoms of sepsis can increase my chances of survival.					
Timely treatment of infections can increase my chances of survival from sepsis.					
I should seek immediate medical care if I have an infection that is not getting better, or is getting worse.					
[Self-Efficacy]	Strongly disagree	Disagree	Neutral	Agree	Strongly agree
I am confident that I can prevent infections that can lead to sepsis.					
I am confident that I can talk to a healthcare professional if I have an infection that is not getting better or is getting worse.					
I am confident that I can recognize the signs and symptoms of sepsis.					
I am confident that I can seek immediate medical care if I suspect sepsis.					

Programmer: Use the following section for Women who care for a child ≤ 12 years old. Renumber as appropriate.

Next, we are going to ask you some questions to learn more about your perspective on infections and sepsis. Please give us your honest responses. There are no right or wrong answers to any of these questions.

We’d like to provide you with a definition for sepsis to assist you in answering the following questions:

Sepsis is the body’s extreme response to an infection. It is life-threatening, and without timely treatment, sepsis can rapidly lead to tissue damage, organ failure, and death.

Please answer the following questions about YOUR CHILD/CHILDREN WHO IS 12 YEARS OLD OR YOUNGER for whom you currently make health care decisions and indicate the extent to which you agree with the following statements, from strongly disagree to strongly agree.

[Perceived Susceptibility]	Strongly disagree	Disagree	Neutral	Agree	Strongly agree
My child is at risk of developing infections that could lead to sepsis.					
My child is at risk of developing sepsis.					
[Perceived Severity]	Strongly disagree	Disagree	Neutral	Agree	Strongly agree
If my child developed sepsis, it could cause severe problems, such as tissue damage and organ failure.					
If my child developed sepsis, it could lead to death.					
[Perceived Benefits]	Strongly disagree	Disagree	Neutral	Agree	Strongly agree
If I take proper care of my child’s chronic condition(s) (if my child has them), this will decrease their chances of developing infections that can lead to sepsis.					
If I practice good hand hygiene, this will decrease my child’s chances of developing infections that can lead to sepsis.					
If I keep my child’s wounds clean and covered until healed, this will decrease their chances of developing infections that can lead to sepsis.					
If my child gets recommended vaccinations, this will decrease their chances of developing infections that can lead to sepsis.					
Fast recognition of the signs and symptoms of sepsis can increase my child’s chances of survival.					
Timely treatment of infections can increase my child’s chances of survival from sepsis.					
I should seek immediate medical care for my child if they have an infection that is not getting better, or is getting worse.					
[Self-Efficacy]	Strongly disagree	Disagree	Neutral	Agree	Strongly agree
I am confident that I can prevent infections that can lead to sepsis in my child.					
I am confident that I can talk to a healthcare professional if my child has an infection that is not getting better or is getting worse.					
I am confident that I can recognize the signs and symptoms of sepsis in my child.					
I am confident that I can seek immediate medical care if I suspect sepsis in my child.					

Programmer: Use the following section for Women who care for an elderly adult 65+. Renumber as appropriate.

Next, we are going to ask you some questions to learn more about your perspective on infections and sepsis. Please give us your honest responses. There are no right or wrong answers to any of these questions.

We’d like to provide you with a definition for sepsis to assist you in answering the following questions:

Sepsis is the body’s extreme response to an infection. It is life-threatening, and without timely treatment, sepsis can rapidly lead to tissue damage, organ failure, and death.

Please answer the following questions about the OLDER ADULT FAMILY MEMBER (AGE 65 YEARS OR OLDER) for whom you are currently the primary caregiver and indicate the extent to which you agree with the following statements, from strongly disagree to strongly agree.

[Perceived Susceptibility]	Strongly disagree	Disagree	Neutral	Agree	Strongly agree
My older adult family member is at risk of developing infections that could lead to sepsis.					
My older adult family member is at risk of developing sepsis.					
[Perceived Severity]	Strongly disagree	Disagree	Neutral	Agree	Strongly agree
If my older adult family member developed sepsis, it could cause severe problems, such as tissue damage and organ failure.					
If my older adult family member developd sepsis, it could lead to death.					
[Perceived Benefits]	Strongly disagree	Disagree	Neutral	Agree	Strongly agree
If I help my older adult family member take proper care of their chronic condition(s) (if my family member has them), this will decrease their chances of developing infections that can lead to sepsis.					
If I help my older adult family member practice good hand hygiene, this will decrease their chances of developing infections that can lead to sepsis.					
If I help my older adult family member keep their wounds clean and covered until healed, this will decrease their chances of developing infections that can lead to sepsis.					
If my older adult family member gets recommended vaccinations, this will decrease their chances of developing infections that can lead to sepsis.					
Fast recognition of the signs and symptoms of sepsis can increase my older adult family member’s chances of survival.					
Timely treatment of infections can increase my older adult family member’s chances of survival from sepsis.					
I should help my older adult family member seek immediate medical care if they have an infection that is not getting better, or is getting worse.					
[Self-Efficacy]	Strongly disagree	Disagree	Neutral	Agree	Strongly agree
I am confident that I can help my older adult family member prevent infections that can lead to sepsis.					
I am confident that I can help my older adult family member talk to a healthcare professional if they have an infection that is not getting better or is getting worse.					
I am confident that I can help my older adult family member recognize the signs and symptoms of sepsis.					
I am confident that I can help my older adult family member seek immediate medical care if I/they suspect sepsis.					

BEHAVIOR

Programmer: Include one question per page

Programmer: Use the following section for Healthy adults 65+ and Men 65+ with one or more chronic conditions. Renumber as appropriate.

42. In the past 12 months, how often did you speak with your healthcare professionals about the following?

	Never	Rarely	Sometimes	Often	Always	Do not know /cannot recall	Did not visit healthcare professional in past 12 months
Infections							
Sepsis							
Who is at-risk for sepsis							
Signs & symptoms of sepsis							
How to seek immediate medical care when you suspect sepsis							
How to prevent infections that can lead to sepsis and sepsis							

43. What are the barriers that make it hard for you to have conversations about how to prevent infections that can lead to sepsis and sepsis? Select all that apply.

• I am not familiar enough with these topics.

• I do not understand these topics.

• I am not interested in these topics.

• I do not have time to educate myself about these topics.

• I do not think sepsis is a big problem for me.

• I do not think infections that can lead to sepsis are a big problem for me.

• I do not have a healthcare provider with whom I can discuss these topics.

• I feel frightened or worried when I talk about these topics.

• Other, please explain: ___________

• I do not have any barriers to having conversations about these topics.

• Do not know/cannot recall

• Prefer not to answer

44. Did you get a flu vaccine for the 2019-2020 flu season?

• Yes

• No

45. What are the barriers that make it hard for you to prevent infections that can lead to sepsis or sepsis? Select all that apply.

• I am not able to get to a doctor to discuss the steps needed to prevent infections that can lead to sepsis or sepsis.

• I am not able to access or afford supplies for wound care that I would need to prevent infections that can lead to sepsis or sepsis.

• I am not familiar enough with how to prevent infections that can lead to sepsis or sepsis.

• I do not know if I need to get any vaccinations.

• I do not want to get vaccinations.

• I do not think it is possible for me to prevent infections that can lead to sepsis or sepsis.

• I do not think sepsis is a big problem for me.

• I do not think infections that can lead to sepsis are a big problem for me.

• I do not think it is important to prevent infections that can lead to sepsis or sepsis.

• I do not have time to take all the steps needed to prevent infections that can lead to sepsis or sepsis.

• My health makes it hard for me to take all the steps needed to prevent infections that can lead to sepsis or sepsis.

• Other, please explain: ___________

• I have not encountered any barriers to preventing infections that can lead to sepsis or sepsis.

• I do not try to prevent infections that can lead to sepsis or sepsis.

• Do not know/cannot recall

• Prefer not to answer

46. In the last X months, have you looked for information about infections that can lead to sepsis or sepsis? (12 months [pretest]/2 months [posttest])

• Yes

• No

• Do not know/cannot recall

Programmer: For respondents who checked “Yes” above to Q46, ask question 57.

For all other respondents, continue to Q58.

Programmer: Use the following section for Women who care for a child ≤ 12 years old. Renumber as appropriate.

Please answer the following questions about YOUR CHILD/CHILDREN WHO IS 12 YEARS OLD OR YOUNGER for whom you currently make health care decisions.

47. In the past 12 months, how often did you speak with your child’s healthcare professionals about the following?

	Never	Rarely	Sometimes	Often	Always	Do not know /cannot recall	Did not visit healthcare professional in past 12 months
Infections							
Sepsis							
Who is at-risk for sepsis							
Signs & symptoms of sepsis							
How to seek immediate medical care when you suspect sepsis							
How to prevent infections that can lead to sepsis and sepsis							

48. What are the barriers that make it hard for you to have conversations about how to prevent infections that can lead to sepsis and sepsis? Select all that apply.

• I am not familiar enough with these topics.

• I do not understand these topics.

• I am not interested in these topics.

• I do not have time to educate myself about these topics.

• I do not think sepsis is a big problem for my child.

• I do not think infections that can lead to sepsis are a big problem for my child.

• My child does not have a healthcare provider with whom I can discuss these topics.

• I feel frightened or worried when I talk about these topics.

• Other, please explain: ___________

• I do not have any barriers to having conversations about these topics.

• Do not know/cannot recall

• Prefer not to answer

49. Did your child get a flu vaccine for the 2019-2020 flu season?

• Yes

• No

• Do not know

50. What are the barriers that make it hard for you to prevent infections that can lead to sepsis or sepsis in your child? Select all that apply.

• I am not able to get to a doctor with my child to discuss the steps needed to prevent infections that can lead to sepsis or sepsis.

• I am not able to access or afford supplies for wound care that I would need to prevent infections that can lead to sepsis or sepsis in my child.

• I am not familiar enough with how to prevent infections that can lead to sepsis or sepsis in my child.

• I do not know if my child needs to get any vaccinations.

• I do not want my child to get vaccinations.

• I do not think it is possible for me to prevent infections that can lead to sepsis or sepsis in my child.

• I do not think sepsis is a big problem for my child.

• I do not think infections that can lead to sepsis are a big problem for my child.

• I do not think it is important to prevent infections that can lead to sepsis or sepsis in my child.

• I do not have time to take all the steps needed to prevent infections that can lead to sepsis or sepsis in my child.

• My child’s health or my own health make it hard for me to take all the steps needed to prevent infections that can lead to sepsis or sepsis.

• Other, please explain: ___________

• I have not encountered any barriers to preventing infections that can lead to sepsis or sepsis in my child.

• I do not try to prevent infections that can lead to sepsis or sepsis in my child.

• Do not know/cannot recall

• Prefer not to answer

51. In the last 12 months, have you looked for information about infections that can lead to sepsis or sepsis for your child?

• Yes

• No

• Do not know/cannot recall

Programmer: For respondents who checked “Yes” above to Q51, ask question 57.

For all other respondents, continue to Q58.

Programmer: Use the following section for Women who care for an elderly adult 65+. Renumber as appropriate.

Please answer the following questions about the OLDER ADULT FAMILY MEMBER (AGE 65 YEARS OR OLDER) for whom you are currently the primary caregiver.

52. In the past 12 months, how often did you speak with your older adult family member’s healthcare providers/help them to speak with their healthcare professionals about the following?

	Never	Rarely	Sometimes	Often	Always	Do not know /cannot recall	Did not visit healthcare professional in past 12 months
Infections							
Sepsis							
Who is at-risk for sepsis							
Signs & symptoms of sepsis							
How to seek immediate medical care when you suspect sepsis							
How to prevent infections that can lead to sepsis and sepsis							

53. What are the barriers that make it hard for you to have conversations/help your older adult family member have conversations about how to prevent infections that can lead to sepsis and sepsis? Select all that apply.

• I am not familiar enough with these topics.

• I do not understand these topics.

• I am not interested in these topics.

• I do not have time to educate myself about these topics.

• I do not think sepsis is a big problem for my older adult family member.

• I do not think infections that can lead to sepsis are a big problem for my older adult family member.

• My older adult family member does not have a healthcare provider with whom I can discuss these topics.

• I feel frightened or worried when I talk about these topics.

• Other, please explain: ___________

• I do not have any barriers to having conversations about these topics.

• Do not know/cannot recall

• Prefer not to answer

54. Did your older adult family member get a flu vaccine for the 2019-2020 flu season?

• Yes

• No

• Do not know

55. What are the barriers that make it hard for you to prevent infections that can lead to sepsis or sepsis in your older adult family member? Select all that apply.

• I am not able to get to a doctor with my older adult family member to discuss the steps needed to prevent infections that can lead to sepsis or sepsis.

• I am not able to access or afford supplies for wound care that I would need to prevent infections that can lead to sepsis or sepsis for my older adult family member.

• I am not familiar enough with how to prevent infections that can lead to sepsis or sepsis in my older adult family member.

• I do not know if my older adult family member needs to get any vaccinations.

• I do not want my older adult family member to get vaccinations.

• I do not think it is possible for me to prevent infections that can lead to sepsis or sepsis in my older adult family member.

• I do not think sepsis is a big problem for my older adult family member.

• I do not think infections that can lead to sepsis are a big problem for my older adult family member.

• I do not think it is important to prevent infections that can lead to sepsis or sepsis in my older adult family member.

• I do not have time to take all the steps needed to prevent infections that can lead to sepsis or sepsis in my older adult family member.

• My older adult family member’s health makes it hard for me to take all the steps needed to prevent infections that can lead to sepsis or sepsis.

• Other, please explain: ___________

• I have not encountered any barriers to preventing infections that can lead to sepsis or sepsis in my older adult family member.

• I do not try to prevent infections that can lead to sepsis or sepsis in my older adult family member.

• Do not know/cannot recall

• Prefer not to answer

56. In the last 12 months, have you looked for information about infections that can lead to sepsis or sepsis for your older adult family member?

• Yes

• No

• Do not know/cannot recall

Programmer: For respondents who checked “Yes” above to Q56, ask question 57.

For all other respondents, continue to Q58

SOURCES OF INFORMATION

57. To whom or where did you ACTUALLY go to get information about infections that can lead to sepsis, and/or sepsis? (select all that apply)

• My doctor/healthcare provider’s office

• Health websites/health-related mobile apps (e.g., WebMD, MayoClinic)

• Centers for Disease Control and Prevention (CDC) website

• Health magazines

• Family members and/or friends

• Newspapers

• Television

• Radio

• Social media (e.g., Facebook, Twitter, Instagram)

• Other (please specify:_______________)

• I have not tried to learn about sepsis

58. In an ideal world, where would you PREFER to get information about sepsis? (select all that apply)

• Family members and/or friends

• My doctor/healthcare provider

• Health websites/health-related mobile apps (e.g., WebMD, Mayo Clinic, etc.). Please specify: _______________.

• Health groups/organizations (e.g., National Institutes of Health, American Cancer Society, etc.). Please specify: _______________.

• Media (e.g., television, radio, newspapers, health magazines, etc.). Please specify: _______________.

• Social media (e.g., Facebook, Instagram, Twitter, LinkedIn, etc.). Please specify: _______________.

• Podcasts. Please specify: _______________.

• Blogs. Please specify: _______________.

• Other. Please specify: _______________.

• Do not know/unsure

59. Did you know that the CDC has a Get Ahead of Sepsis webpage with resources you can use to learn about sepsis?

• Yes

• No

Programmer: If respondent selects Yes to Q59, proceed to Q60
If respondent selects No to Q59, skip Demographic Characteristics section.

60. How did you learn about CDC’s Get Ahead of Sepsis resources? (select all that apply)

• My doctor/healthcare provider’s office

• Health websites/health-related mobile apps (e.g., WebMD, Mayo Clinic)

• Centers for Disease Control and Prevention (CDC) website

• Family members and/or friends

• Social media (e.g., Facebook, Twitter, Instagram)

• Other (please specify:_______________)

• Do not know/cannot recall

DEMOGRAPHIC CHARACTERISTICS

61. How would you describe your racial background? Select all that apply.

• White

• Black or African American

• Asian

• Native Hawaiian or Other Pacific Islander

• American Indian or Alaska Native

• Other, please specify: ____________

• Prefer not to answer

62. Are you Hispanic or Latino?

• Yes

• No

• Prefer not to answer

63. What language do you primarily use at home (i.e., when speaking with friends or family)? 

• English

• Spanish 

• Chinese (including Mandarin, Cantonese, and other Chinese languages)

• French

• Portuguese

• Vietnamese

• Other (please specify: _______________)

• Prefer not to answer

64. What is the highest degree you have received? (Please select only one)

• Some high school

• High school graduate (or equivalent)

• Some college or technical school (1–4 years, no degree)

• Associate or technical degree

• Bachelor’s (4-year college) degree

• Master’s degree

• Professional or doctoral degree (MD, JD, PhD, etc.)

• Prefer not to answer

65. How confident are you filling out medical forms by yourself? (Please select only one)

• Extremely

• Quite a bit

• Somewhat

• A little bit

• Not at all

Thank you for taking the time to participate in this important survey!

FOR POST TEST ONLY: To learn more about infection prevention and sepsis, please visit www.cdc.gov/sepsis.

Public reporting burden of this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-0572