Survey

Form Approved

OMB No. 0920-xxxx

Expires xx/xx/xxxx

Appendix 2: Validated survey instrument to assess if the interventions within the stewardship initiative were acceptable, appropriate, and feasible.

Interventions to be studied will be based on the Core Elements of Outpatient Antibiotic Stewardship (see Table below). We determine acceptability, appropriateness, and feasibility of each intervention

CDC Core Elements	Interventions
Action (Policy & Practice)	Delayed Prescriptions
	Quick Visit templated notes
	Azithromycin Justification
Tracking and Reporting	Prescribing Dashboard
	Professional conversations to review quality measures
Education & Expertise	Patient Symptoms checklist
	Site Visits
Commitment	Commitment Posters

Acceptability of Intervention Measure (AIM)

	Completely disagree	Disagree	Neither agree nor disagree	Agree	Completely agree
1. (INSERT INTERVENTION) meets my approval.					
2. (INSERT INTERVENTION) is appealing to me.					
3. I like (INSERT INTERVENTION).					
4. I welcome (INSERT INTERVENTION).					

Intervention Appropriateness Measure (IAM)

	Completely disagree	Disagree	Neither agree nor disagree	Agree	Completely agree
1. (INSERT INTERVENTION) seem fitting.					
2. (INSERT INTERVENTION) seem suitable.					
3. (INSERT INTERVENTION) seem applicable.					
4. (INSERT INTERVENTION) seem like a good match.					

Feasibility of Intervention Measure (FIM)

	Completely disagree	Disagree	Neither agree nor disagree	Agree	Completely agree
1. (INSERT INTERVENTION) seem implementable.					
2. (INSERT INTERVENTION) seem possible.					
3. (INSERT INTERVENTION) seem doable.					
4. (INSERT INTERVENTION) seem easy to use.					

Public reporting burden of this collection of information is estimated to average 5 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 (0920-xxxx).