Urine Collection, Storage and Preservation Laboratory Pr

Appendix M4
Urine Collection, Storage and Preservation Laboratory Practice Survey
INTRODUCTION
Form Approved
OMB No. 0920-XXXX
Exp. Date xx/xx/20xx
Purpose of the Survey: This survey is being performed for the Centers for Disease Control and Prevention
(CDC) and the American Society for Microbiology (ASM) to understand laboratories' current practices related
to the collection, storage and preservation of urine for microbiological culture. The goal of the study is to
improve the diagnosis and management of patients with urinary tract infection. This survey will take
approximately 20 minutes to complete.
Security Information: All information collected in this survey will be kept in a secure manner. We ask you to
include your CLIA number to ensure that only one response per laboratory is recorded. We also ask you to
include your email address to follow-up if needed. Your CLIA number and email address will not be stored in
a database and they will not be linked to your survey responses. Your IP address will NOT be retained.
Participation is voluntary; you are free to withdraw from this survey at any time. If at any point you do not want
to continue, you can simply leave this website. If you do not click on the “done" button at the end of the
survey, your answers and participation will not be recorded.
Asterisks (*): Questions marked with an asterisk require an answer before you can proceed to the next
question.
How the findings will be used: The results from the survey will be compiled and shared in aggregate as a
learning tool, presented at professional conferences, and potentially published in a professional journal in the
field of laboratory science.
Contact Information: If you have concerns or questions about this survey please address them
to [email protected].
Agreement: By beginning the survey, you acknowledge that you have read this information and agree to
participate in this survey, with the knowledge that you are free to withdraw your participation at any time
without penalty.
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 Information
Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920XXXX).

Thank you for taking the time to complete this CDC and ASM survey. Your feedback is important for guiding
CDC and ASM in their efforts to understand current laboratory urine practice. The survey should take
approximately 20 minutes of your time. All answers will remain completely anonymous.

* 1. Position/Title of Person Completing Survey:

* 2. Email address:

* 3. Laboratory Name:

* 4. CLIA #:

* 5. How did you learn about this survey?
Laboratory Response Network Request
ClinMicroNet
DivCNet
Clinical Microbiology Issues Update
Microbe, ASM's monthly news magazine
Other (please specify)

* 6. Did you already fill out this survey?
Yes

If answered "Yes", respondents have completed survey.

No

7. Date:
MM
12/05/2015

DD

/

YYYY

/

Urine Collection, Storage and Preservation Laboratory Practice Survey
DEMOGRAPHICS

* 8. Which of the following best describes your laboratory setting? (Select the best choice.)
University hospital/Academic medical center
City/County/State Hospital
Military/VA Hospital
Other type of hospital that is not listed above
Independent laboratory
Public Health Department,non-hospital
Physician office/ambulatory care laboratory
Other (please specify)

* 9. How would you characterize your institution?
For profit
Non-profit

* 10. How many pathologists or other physicians are in your laboratory? (Do not include residents,
fellows or trainees/medical students.)

* 11. Is your laboratory located in an institution that provides direct patient care?
Yes
No

Urine Collection, Storage and Preservation Laboratory Practice Survey
DEMOGRAPHICS
* 12. My institution is
hospital based.
non-hospital based.

* 13. What kind of patient population is at your institution? (Select all that apply.)
Inpatient
Outpatient
Non-patient
Other (please specify)

Urine Collection, Storage and Preservation Laboratory Practice Survey
DEMOGRAPHICS
* 14. How many hospital beds does the microbiology section serve?
>500 beds
101-500 beds
50-100 beds
<50 beds
Only have outpatients

* 15. What is your laboratory's zip code?

* 16. Are any of your laboratory staff currently members of the American Society for Microbiology
(ASM)?
Yes
No

If answered "No" or "Do not know",
respondents skip to question 18.

Do not know

Urine Collection, Storage and Preservation Laboratory Practice Survey
DEMOGRAPHICS

* 17. Do any of those members subscribe to (select all that apply)-ASM's ClinMicroNet listserv
ASM's DivCNet listserv
No, do not subscribe
Do not know

Urine Collection, Storage and Preservation Laboratory Practice Survey
DEMOGRAPHICS
* 18. Does the microbiology laboratory have a doctoral-level clinical scientist or consultant?
Yes

If answered "No", respondents skip to question 20.

No

Urine Collection, Storage and Preservation Laboratory Practice Survey
DEMOGRAPHICS
* 19. What is their board certification? (Select all that apply.)
D(ABMM) Diplomate, American Board of Medical Microbiology
D(ABB) Diplomate, American Board of Bioanalysis, HCLD (High Complexity Laboratory Director)
D(ABB) Diplomate, American Board of Bioanalysis, BCLD (Bioanalyst Clinical Laboratory Director)
Ph.D., other board certified
Ph.D., non-board certified
ABP (American Board of Pathology) Sub-boarded in Medical Microbiology
ABIM (American Board of Internal Medicine) Sub-boarded in Infectious Disease
M.D./D.O.
Do not know
Other (please specify)

Urine Collection, Storage and Preservation Laboratory Practice Survey
CURRENT PRACTICE

* 20. Does your laboratory perform urine cultures?
Yes

If answered "No", respondents have completed survey.

No

Urine Collection, Storage and Preservation Laboratory Practice Survey
CURRENT PRACTICE
* 21. Do you refrigerate or use a chemical preservative if urines cannot be delivered within two
hours?
Yes

If answered "No", respondents skip to question 23.

No

Urine Collection, Storage and Preservation Laboratory Practice Survey
CURRENT PRACTICE
* 22. What type of preservation do you use if cultures cannot be delivered within two hours? (Select
all that apply.)
Refrigeration
Boric Acid
Other (please specify)

* 23. Do you have a specimen acceptability and rejection policy?
Yes
No

Urine Collection, Storage and Preservation Laboratory Practice Survey
CURRENT PRACTICE
* 24. If so, do you...(select all that apply.)
reject specimens that do not meet the acceptability criteria.
accept specimens that do not meet criteria but add a comment.
not applicable; we do not reject specimens.

* 25. Do you provide instructions to females collecting a midstream urine to clean their genital area
prior to collection?
Yes
No

* 26. Do you provide instructions to males to retract their foreskin and clean their penis before they
collect a midstream urine?
Yes
No

* 27. What type of specimen(s) do you receive for newborns and children? (Select all that apply.)
Diaper
Suprapubic aspirate
Bagged collection
Straight catheterization
Not applicable; no pediatric population.
Other (please specify)

* 28. Are urines pre-screened prior to culture?
Yes
No

If answered "No", respondents skip to question 30.

Urine Collection, Storage and Preservation Laboratory Practice Survey
CURRENT PRACTICE

* 29. What are the pre-screening methods? (Select all that apply.)
Biochemical/dipstick
Microscopic UA, manual
Automated: iQ200 (IRIS)
Automated: UF1000i (Sysmex)
Automated: Other
UriScreen
Bacterial staining (eg Gram, methylene blue, acridine orange)
Other Methods (please specify)

* 30. Do you know your approximate contamination rate?
Yes
No

Urine Collection, Storage and Preservation Laboratory Practice Survey

* 31. What is it? (Enter not applicable if you do not know.)

* 32. Do you use percentage of contamination of urine cultures as a clinical monitor for quality
assurance purposes?
Yes

If answered "No", respondents have completed survey.

No

* 33. What is the threshold of acceptability?