Form 0920-21DZ Harm Reduction Toolkit for Non-Prescription Syringe Sale

Form Approved

OMB No. 0920-New

Expiration Date: XX/XX/XXXX

Harm Reduction Toolkit for Non-Prescription Syringe Sales in Community Pharmacies

Attachment 6

Pre-test Survey

Public reporting burden of this collection of information is estimated to average 30 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: OMB-PRA (0920-New)

Thank you for agreeing to participate in the Pharmacy-Based Harm Reduction Study.  Please complete this survey about you and your experiences with non-prescription syringe sale.  
 
Your responses on this survey are confidential and your answers will have no impact on your employment. While we require you input your email address here, this is only so we can connect your survey with your participant ID number.  Once we have connected your survey and your participant ID, your email will be disconnected from the survey. 
 
If you have any questions about this survey or the broader study, you can contact Lane Edwards at [email protected]  

Demographics: 

1. Email address 

2. Gender Identity (Select all that apply)

1. Woman

2. Man

3. Non-binary

4. Transgender

5. Prefer to self-described (please specify): ____________

6. Prefer not to respond

3. Age (short answer) 

4. Race (select all that apply) 

a. American Indian or Alaska Native

b. Asian

c. Black or African American

d. Native Hawaiian or Other Pacific Islander

e. White

5. Ethnicity? 

1. Hispanic or Latino

2. Not Hispanic or Latino

6. Please list the name(s) of the pharmacy or pharmacies at which you currently are employed (short answer) 

7. What is your position at the pharmacy? (Select all that apply) 

1. Head pharmacist/pharmacist in charge  

2. Pharmacist 

3. Assistant pharmacist  

4. Pharmacy technician  

5. Pharmacy cashier  

6. Pharmacy intern 

7. Other (write in) 

8. How many years have you been employed as pharmacy staff (short answer) 

Knowledge and attitude: 

9.  People with drug problems who are not willing to accept abstinence as their goal should be offered options that aim to reduce the harm associated with their continued drug use. 

                      1                    2                 3                   4                               5 

          Strongly Agree     Agree       Neither      Disagree       Strongly Disagree 

10.  Making clean injecting equipment available to injecting drug users is likely to reduce the rate of HIV infection.  

                        1                    2                 3                   4                               5 

          Strongly Agree     Agree       Neither      Disagree       Strongly Disagree 

11. Abstinence is the only acceptable treatment goal for people who use illicit drugs. 

                        1                    2                 3                   4                               5 

          Strongly Agree     Agree       Neither      Disagree       Strongly Disagree 

 

12. State NPSS law – please select all options that you believe apply to the state's law in which your pharmacy is located regarding the sale on non-prescription syringes by pharmacy staff (select all that apply) 

Non-prescription syringe sale explicitly permitted	Non-prescription syringe sale is explicitly forbidden
There are no specific laws in my state explicitly addressing NPSS	Personnel are required to ask the purpose of the syringe use
Upon sale, personnel must provide written information on the prevention of bloodborne disease, drug treatment, and safe disposal of syringes.	Non-prescription syringe sale is permitted if a legitimate medical need has been demonstrated (could include the prevention of the transmission of communicable diseases)
A sharps container must be distributed with every syringe purchase	Personnel are required to keep a log with the information about the purchase and purchaser
Purchasers must show valid photo ID	Only individuals 18 or older can be sold non-prescription syringes
Pharmacists must report if they think syringes will be used for illegal drug use.	Only specific pharmacy staff (such as pharmacists) may complete NPSS sales.
Up to 10 syringes can be sold at a time	Other (write in)

13. Has a pharmacy staff member ever been held civilly or criminally liable for selling a syringe to someone who used it for injecting drugs? 

1. Yes 

2. No 

14. Did your pharmacy provide you with any information regarding your states NPSS laws? 

1. Yes 

2. No 

3. Other (write in) 

15. According to research, does access to non-prescription syringes increase rates of drug use?  

1. Yes  

2. No  

3. I don’t know 

16. Does your pharmacy participate in non-prescription syringe sale?  

1. Pharmacy staff are expected to provide non-prescription syringes to all customers seeking them 

2. Pharmacy staff are permitted, but not expected, to provide non-prescription syringes to all customers seeking them  

3. Pharmacy staff have not been informed of expectations regarding the prevision of non-prescription syringes to customers seeking them 

4. Pharmacy staff are discouraged, but not forbidden, to provide non-prescription syringes to all customers seeking them 

5. Pharmacy staff are forbidden from providing non-prescription syringes to all customers seeking them 

6. Other (write in)  

17. What is your opinion on pharmacies selling non-prescription syringes to people who use injection drugs? 

                       1                              2                 3                     4                               5                         

         Strongly Opposed     Opposed       Neither          In favor        Strongly in favor i                                                                                                           

18.  What are your feelings about personally selling Non-Prescription Syringe Sale to people who use injection drugs? 

                         1                              2                 3                     4                               5 

          Strongly Opposed     Opposed       Neither      Supportive        Strongly Supportive    

                                              

19. Indicate your perception of your level of ability to sell non-prescription syringes: 

1	2	3	4	5
No level of competence	Low level of competence	Average level of competence	Moderately high level of competence	High level of competence

20. Indicate your level of experience with non-prescription syringes: 

1	2	3	4	5
No experience	Little experience	Some experience	Substantial experience	Extensive experience

21. Indicate your comfort level completing sales to people you believe to be illegal drug users: 

1	2	3	4	5
Very uncomfortable	Slightly uncomfortable	Neutral	Comfortable	Very comfortable

 

Think of your last three non-prescription syringe customers, how do you think these customers would review your interaction.  

22. Your professionalism out of five stars: 

1. 1 star 

2. 2 stars 

3. 3 stars 

4. 4 stars 

5. 5 stars 

23. Your friendliness out of five stars: 

1. 1 star 

2. 2 stars 

3. 3 stars 

4. 4 stars 

5. 5 stars 

 

24. Your respectfulness out of five stars: 

1. 1 star 

2. 2 stars 

3. 3 stars 

4. 4 stars 

5. 5 stars 

 

25. Your comfort with the transaction out of 5 stars:  

1. 1 star 

2. 2 stars 

3. 3 stars 

4. 4 stars 

5. 5 stars 

 

26. How often do you personally sell non-prescription syringes?  

1. At least once a day 

2. At least once a week 

3. At least once a month 

4. At least once every 3 months 

5. At least once a year 

6. Never 

 

27.  What’s the most uncomfortable element for you about doing NPSS sales? (fill in) 

 

Short Answer Scenario: 

Please review the following scenario and provide a step-by-step description of how you would handle the following non-prescription syringe sale.  

Here is an example of the step-by-step description we are looking for a concierge at a hotel: 

You are working at the front desk of your hotel; a man approaches the front desk with his luggage. Please describe how you would handle the situation: 

•  Welcome the guest to the hotel and ask them for the name for their reservation

•  Find their reservation in the system 

•  Confirm the details of the reservation with the guest  

•  Describe the hotel amenities and rules 

•  Give the guest their room key and directions to the room 

•  Offer to help them with their luggage and make necessary arrangements 

• ask them if they need anything else, and if they do, help them with whatever they needed. 

• If they need nothing else, tell them to contact the front desk if they need anything, and wish them a nice stay. 

• leave and return to the front desk 

28.  Present a short video scenario in which an individual comes into the pharmacy and asks to buy some syringes 

(short answer, advance to next page) 

29. Present a short video scenario in which an individual asks for bee stingers (slang for a specific syringe size).  

(short answer, advance to next page) 

30. Present a short video scenario for pharmacist in which they are giving a consultation and the individual indicates they may want to seek treatment (short answer – pharmacist only)  

(short answer, advance to next page) 

32. How much do your procedures responding to these scenarios differ from other staff in the pharmacy? 

1. Greatly 

2. Moderately  

3. Slightly 

4. Not at all 

5. I don’t know 

 

Distribution data 

33. Please describe any posted signage or materials regarding NPSS in your pharmacy (short answer) 

34.  In the past week, how many non-prescription syringes sales did you personally process?) (fill in #) 

35. In the past week, how many injection drug use related consultations did you personally provide? (fill in #) 

36. In the past week, how many injection drug use related referrals did you personally make?  (fill in #)