0920-22CC BAA Consumer Pre Campaign Screener and Survey

Attachment C: BAA Consumer Pre-Campaign Screener and Survey

Form Approved

OMB No. 0920-XXX

Expiration Date XX/XX/XXXX

baa consumer pre-campaign SCREENER [ALL]

Target Audiences

• Healthy adults who visit urgent care (ages 18-64 for participants who live in TN and IA and ages 19-64 for participants who live in NE)

• Community dwelling older adults, 65+  

• Family caregivers (18+ for participants who live in TN and IA and 19+ for participants in live in NE) of nursing home (long-term care) residents  

General Instructions for Programmer

1. Place Hide all subheadings of sections and questions from respondents.

2. Hide all programmer’s instructions from respondents.

3. For questions with the “Select all that apply” option, do not allow respondents to select any other option if they select “Prefer not to say,” “Do not know/cannot recall,” “Not sure,” “Nothing,” or “None of the above.”

4. Terminate also means ineligible.

5. Terminate all eligible respondents immediately.

6. Present the “Ineligibility Message” whenever a response terminates the survey.

Thank You for participating in this survey. The results 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.

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

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

• Yes

• No [INELIGIBLE/TERMINATE]

Programmer: If “No” to Q1, TERMINATE. If “Yes,” proceed to Q2. 

2. In what ZIP Code and State do you live? ______

Programmer: Targeted states include Iowa (IA), Nebraska (NE), and Tennessee (TN). 

Programmer: Approved ZIP Codes include XXXXX, XXXXX, XXXXX, etc. If not within one of the target states and approved ZIP Codes, TERMINATE, otherwise, proceed to Q3.

3. How old are you? _ _ years

• Prefer not to answer [INELIGIBLE/TERMINATE]

If the respondent is a resident of Nebraska and under 19 years of age, TERMINATE and present the INELIGIBILITY message.

For all other target States, If the respondent is under 18 years of age, TERMINATE and present the INELIGIBILITY message.

If “Prefer not to answer,” TERMINATE.

If the respondent is eligible based on age, proceed to Q4.

4. What sex were you assigned at birth, on your original birth certificate?

• Male

• Female

• Refused

• I don’t know

5. Do you currently describe yourself as male, female, transgender?

• Male

• Female

• Transgender

• None of these

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

• English

• Spanish

• English and Spanish equally

• Another language, please specify: ______________________

• Prefer not to answer

7. What language do you primarily use when looking for, reading, or communicating about health information?

• English

• Spanish

• English and Spanish equally

• Another language, please specify: ______________________

• Prefer not to answer

8. Have you visited an urgent care clinic to receive medical care at least once in the past 12 months for yourself (not for the care of a loved one)? Urgent care clinics are freestanding clinics that treat patients for unscheduled or walk-in infections or injuries but DO NOT include a pharmacy (clinics in CVS or Walgreens are not considered urgent care clinics), a store, or an emergency department.

• Yes

• No

• Not sure

Programmer: If the respondent selects "No" or “Not sure” to Q8, proceed to Q11, else proceed to Q9.

9. When you visited an urgent care clinic, did you do so for a respiratory infection, such as a common cold, flu, or COVID-19?

• Yes

• No

• Do not know/cannot remember

10. How would you rate your overall physical health?

• Excellent

• Very good

• Good

• Fair

• Poor

11. Are you the primary caregiver of a family member who is in a nursing home or long-term care facility? 

• Yes  

• No 

Programmer: Q12 is for adults aged 65+ only

12. What is your current living situation? Select all that apply.

• By myself

• With family members  

• In a nursing home or long-term care facility 

• Other, please specify: _______________________ 

13. Do you, your spouse or partner, or any other member of your household (currently or in the past) work for or at:

	Yes	No
A market research company (involved in doing surveys, focus groups, interviews to understand trends, etc.)		
An advertising agency or public relations/marketing firm		
The media (TV/radio/newspapers/magazines)		
A healthcare setting or a health and wellness organization (e.g., doctor’s office, clinic, hospital, health department, fitness center)		
A healthcare professional (e.g., doctor, nurse, pharmacist, physician assistant, medical assistant, dietician, aid, sitter, social worker)		

Programmer: If the respondent selects “Yes” to any option of Q13, TERMINATE.

Categorize Respondents

Programmer:  

Categorize respondents as “Healthy adults who visit urgent care, 18-64” for all target states except NE. For target states NE categorize as “Healthy adults who visit urgent care, 19-64.”

• Q2 = If the respondent’s age is 18+ AND

• Q8 = Yes AND

• Q9 = Yes AND

• Q10 = Excellent, very good, OR good

Categorize respondents as "Community-dwelling older adults, 65+ " 

• Q2 = 65+ AND

• Q12 = By myself or with family members 

 

Categorize respondents as “Family caregivers of nursing home (long-term care) residents" 

• Q11 = Yes 

Programmer: If a respondent does not fall into one of the above categories TERMINATE and display the “Ineligibility Message,” else display the “Proceed to Survey Message.”

Eligible/Proceed to Survey Message

Thank you for answering the screening questions. We have determined that you are eligible to proceed with this survey. If you have any questions, please contact [name] at [email address] or call phone number XXX-XXX-XXXX or XXX-XXX-XXXX.

Please click on “Proceed to Survey” and answer the questions to the best of your ability.

Ineligibility Message 

Thank you for your willingness to participate in this survey. Unfortunately, you are not eligible to proceed with the survey. If you have any questions, please contact [name] at [email address] or call phone number XXX-XXX-XXXX or XXX-XXX-XXXX.

Thank you for your time. Please click on “Exit Survey” to exit.

baa consumer pre-campaign survey

Exposure to Campaign [ALL]

Programmer: Include one question per page.

Now, we would like to ask you about a CDC campaign on improving antibiotic use that you may or may not have seen or heard about in the past 12 months.

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

Programmer: Rotate Q14 (a - e), the column named “Campaigns” among respondents.

Campaigns	Yes	No	Do not know/ cannot recall
Get Ahead of Antibiotics			
Flip the Script			
Be Antibiotics Aware			
Get Smart About Antibiotics			
Don’t Miss-take Antibiotics			

15. I n the past 12 months, did you see this logo or hear the slogan (“Be Antibiotics Aware,” “Smart Use, Best Care”) anywhere?

• Yes

• No

• Do not know/cannot recall

Programmer: If the respondent selects “Yes” to Q14c and “Yes” or “Do not know/cannot recall to Q15, classify as “Exposed” and proceed to the FREQUENCY AND CHANNEL OF EXPOSURE section.

If the respondent selects “Do not know/cannot recall” to Q14c and “Yes” to Q15, classify as “Exposed” and proceed to the FREQUENCY AND CHANNEL OF EXPOSURE section.

If the respondent selects “No” or “Do not know/cannot recall” to Q14c and “No” or “Do not know/cannot recall” to Q15, classify as “Unexposed” and proceed to KNOWLEDGE section. After the quota of unexposed has been met for each target group then TERMINATE.

Frequency and Channel of Exposure [EXPOSED ONLY]

Programmer: Include one question per page.

You indicated that you had seen or heard the campaign name, Be Antibiotics Aware, or seen the campaign logo in the past 12 months.

16. In the past 12 months, approximately how often did you see CDC’s Be Antibiotics Aware campaign messages, campaign name, or logo in …?

Programmer: Rotate the media options (Poster, Fact sheet, Brochure, etc.).

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: ______________________						

17. In the past 12 months, approximately how often did you see CDC’s Be Antibiotics Aware campaign messages, campaign name, or logo on …?

Programmer: Rotate the media options (Facebook, Instagram, Twitter, etc.).

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: ______________________						

18. In the past 12 months, approximately how often did you see or hear CDC’s Be Antibiotics Aware campaign messages, campaign name, or logo in…?

Programmer: Rotate the media options (Online/Internet Media).

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 (e.g., WebMD, Mayo Clinic)						
Website advertisements						
Online news articles						
Streaming TV/video services (e.g., Hulu, Netflix, [Amazon] Prime Video)						
Streaming Internet radio						
Blogs						
Advertisements on mobile phone (including mobile apps)						
Search engines (e.g., Google)						
Other websites, please specify: ______________________						

19. In the past 12 months, approximately how often did you see or hear CDC’s Be Antibiotics Aware campaign messages, campaign name, or logo on…?

TV and 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: ______________________						

20. In the past 12 months, approximately how often did you see CDC’s Be Antibiotics Aware campaign messages, campaign name, or logo on…?

Programmer: Rotate the media options (Public Places).

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 shopping center or parking lot						
Advertisement in a mall
Advertisement in a grocery store						
Advertisement in a pharmacy (retail or hospital)						
Other public locations, please specify: ______________________						

21. In the past 12 months, approximately how often did you see CDC’s Be Antibiotics Aware 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 and/or healthcare facilities						
Other campaign placements at healthcare facilities, please specify: _____________________						

22. In the past 12 months, approximately how often did you see CDC’s Be Antibiotics Aware campaign messages, campaign name, or logo in …?

Programmer: Rotate the media options (Other Media).

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 or e-newsletters						
Podcasts						
Webcasts or webinars						
Live events						
Other media, please specify: ______________________						

Programmer: If the respondent selects “Never” and/or “Do not know/cannot recall” as responses to ALL options from Q16-Q22, proceed to Q23 (open-ended question), else skip Q23.

23. You indicated that you saw or heard the campaign name, Be Antibiotics Aware, or saw the campaign logo in the past 12 months. Where did you see or hear it?

[open-ended response]

Programmer: If the respondent selects "Never or “Do not know/cannot recall" for ALL options in Q16-Q22, and left Q23 blank, reclassify these respondents as “Unexposed” and proceed to KNOWLEDGE section.

If the 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 Q16-Q22 and filled in Q23 with more than just N/A or NONE, classify as “Exposed” and proceed to KNOWLEDGE section.

Knowledge [ALL]

Next, we would like to ask you a few questions about antibiotics.

Programmer: Include one question per page. RIGHT/WRONG responses have been indicated but do not disclose to respondents.

24. Which types of infections do antibiotics treat?

• Certain infections caused by viruses, including the one that causes COVID-19. [WRONG]

• Certain infections caused by bacteria. [RIGHT]

• Certain infections caused by bacteria and viruses. [WRONG]

• Do not know [WRONG]

25. Which of the following infections do antibiotics treat? Select all that apply.

Programmer: Rotate response options; keep placement of “None of the above” and “Do not know” as is.

• Common cold [WRONG]

• COVID-19 [WRONG]

• Influenza (flu) [WRONG]

• Pneumonia (caused by bacteria) [RIGHT]

• None of the above [WRONG]

• Do not know [WRONG]

Programmer: For Q25, if the respondent selects “Do not know” or “None of the above,” do not allow them to select the other responses.

26. When antibiotics are not needed to treat your infection, taking antibiotics will still help.

• True [WRONG]

• False [RIGHT]

• Unsure [WRONG]

27. Taking antibiotics can lead to side effects that could cause harm.

• True [RIGHT]

• False [WRONG]

• Do not know [WRONG]

28. Which of the following are common side effects of antibiotics? Select all that apply.

Programmer: Rotate response options; keep placement of “None of the above” and “Do not know” as is.

• Rash [RIGHT]

• Nausea [RIGHT]

• Diarrhea [RIGHT]

• Yeast infections [RIGHT]

• None of the above [WRONG]

• Do not know [WRONG]

Programmer: For Q28, if the respondent selects “None of the above” or “Do not know”, do not allow them to select the other responses.

29. Which of the following statement(s) is/are true about antibiotic resistance? Select all that apply.

Programmer: Rotate response options; keep placement of “None of the above” and “Do not know” as is.

• Anytime antibiotics are used, they can contribute to antibiotic resistance. [RIGHT]

• Infections caused by antibiotic-resistant germs are always easy to treat with antibiotics. [WRONG]

• Antibiotic resistance happens when germs no longer respond to the antibiotics designed to kill them. [RIGHT]

• When antibiotics are needed, the benefits usually outweigh the risks of antibiotic resistance. [RIGHT]

• None of the above [WRONG]

• Do not know [WRONG]

Programmer: For Q29, if the respondent selects “None of the above” or “Do not know” do not allow them to select the other responses.

30. When taking antibiotics, _________________________________________. Select all that apply.

Programmer: Rotate response options; keep placement of “None of the above” and “Do not know” as is.

• I should take my antibiotics exactly as my healthcare professional prescribed. [RIGHT]

• It is okay if I skip doses of my antibiotics. [WRONG]

• I can save leftover antibiotics for later. [WRONG]

• It is okay to share my leftover antibiotics with a family member or friend who is not feeling well. [WRONG]

• None of the above [WRONG]

• Do not know [WRONG]

Programmer: For Q30, if the respondent selects “None of the above” or “Do not know” do not allow them to select the other responses.

31. Which of the following can help you feel better when you have a cold? Select all that apply.

Programmer: Rotate response options; keep placement of “None of the above” and “Do not know” as is.

• Drink plenty of fluids. [RIGHT]

• Ask my HCP for an antibiotic. [WRONG]

• Use a clean humidifier or cool mist vaporizer to relieve congestion. [RIGHT]

• Use a saline nasal spray or drops to relieve congestion. [RIGHT]

• Use honey to relieve cough for adults and children at least 1 year of age or older. [RIGHT]

• None of the above [WRONG]

• Do not know [WRONG]

Programmer: For Q31, if the respondent selects “None of the above” and “Do not know”, do not allow them to select the other responses.

Attitudes and Beliefs [ALL EXCEPT FAMILY CAREGIVER]

Programmer: Include one question per page. Do not allow participants to go back and change their answer to a previous question. Remove ATTITUDES AND BELIEFS subcategory headings from tables after programming (e.g., “Perceived Susceptibility”, “Perceived Severity”, etc.).

Keep the following text on the same page as Q32.

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

We would like to provide you with a definition of a few key terms to assist you in answering the following questions:

Antibiotic resistance happens when germs no longer respond to the antibiotics designed to kill them. That means the germs are not killed and continue to grow. It does not mean your body is becoming resistant to antibiotics.

Clostridioides difficile (often called C. difficile or C. diff) is a germ (bacterium) that causes severe diarrhea and colitis, or inflammation of the colon. C. diff infection can lead to severe colon damage and death.

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

Perceived Susceptibility	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
I believe that I may have taken antibiotics when I didn’t need them over the last 12 months.
I believe that I could get an antibiotic-resistant infection.
I believe that any time people take antibiotics, it contributes to antibiotic resistance.
I believe that my healthcare professional(s) may have given me prescriptions for antibiotics when they were not necessary.
I believe that anyone taking antibiotics can experience side effects, such as rash, nausea, and/or diarrhea.
I believe that taking antibiotics can lead to serious side effects, including Clostridioides difficile (or C. diff) infection, life-threatening allergic reactions, or antibiotic-resistant infections.

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

Perceived Severity	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
If I got an antibiotic-resistant infection, it could be very dangerous for me.
I believe that antibiotic resistance is a severe problem that can threaten the health of myself and others.
I believe that antibiotics can sometimes lead to more serious side effects, including Clostridioides difficile (or C. diff) infection, life-threatening allergic reactions, or antibiotic-resistant infections, which can be very dangerous for me.

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

Perceived Benefits	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
I believe that using antibiotics only when needed helps to ensure these drugs will be available for future generations.
I believe that using antibiotics only when needed helps to keep me safe from side effects.
I believe that using antibiotics only when needed helps fight antibiotic resistance.

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

Perceived Barriers to using Antibiotics Appropriately	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
If my healthcare professional told me to wait a few days to see if I feel better before prescribing antibiotics, I would feel inconvenienced.
If my healthcare professional told me I didn’t need antibiotics for my infection, I would feel worried that I wouldn’t feel better.
c. If my healthcare professional told me I didn’t need antibiotics for my infection, I would feel worried that I might get sicker.

36. Please indicate your level of confidence for each of the following questions.

Self-Efficacy	Not at all Confident	Somewhat Confident	Moderately Confident	Confident	Very Confident
When you have a viral infection, how confident are you that you will not need antibiotics?
How confident are you in your ability to discuss your questions and concerns about antibiotics with your healthcare professional?
How confident are you that you will accept your healthcare professional’s recommendation if they say you do not need antibiotics?

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

Perceived importance of discussing appropriate antibiotic use with HCPs	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
When I’m sick, it’s important to talk with my healthcare professionals about what the best treatment is for my respiratory infection.
When I’m sick, but antibiotics aren’t needed, it is important to talk with my healthcare professionals about other ways to feel better.
When I’m sick and antibiotics can help, it is important to talk with my healthcare professionals about the risks of taking antibiotics (e.g., side effects, antibiotic resistance).

Attitudes and Beliefs [FOR FAMILY CAREGIVER] 

38. Now please think about your older adult family member who lives in a nursing home and who is under your care. Please indicate the extent to which you agree with the following statements, from strongly disagree to strongly agree. 

Perceived Susceptibility	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
I believe that my family member may have taken antibiotics when they didn’t need them during the last 12 months.
I believe that my family member could get an antibiotic-resistant infection.
I believe that any time people take antibiotics, it contributes to antibiotic resistance.
I believe that my family member’s healthcare professional(s) may have given prescriptions for antibiotics when they were not necessary.
I believe that anyone taking antibiotics can experience side effects, such as rash, nausea, and/or diarrhea.
I believe that if my family member takes antibiotics it can lead to serious side effects such as Clostridioides difficile (or C. diff) infection or life-threatening allergic reactions.

39. Please continue to think about your older adult family member who lives in a nursing home and who is under your care. Please indicate the extent to which you agree with the following statements, from strongly disagree to strongly agree.  

Perceived Severity	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
If my family member got an antibiotic-resistant infection, it could be very dangerous for them.
I believe that antibiotic resistance is a severe problem that can threaten the health of my family member and others.
I believe that antibiotics can lead to serious side effects such as Clostridioides difficile (or C. diff) infection, which can cause diarrhea and death.

40. Please continue to think about your older adult family member who lives in a nursing home and who is under your care. Please indicate the extent to which you agree with the following statements, from strongly disagree to strongly agree. 

Perceived Benefits	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
I believe that my family member using antibiotics only when needed helps to ensure these drugs will be available for future generations.
I believe that my family member using antibiotics only when needed helps to keep them safe from side effects.
I believe that my family member using antibiotics only when needed helps fight antibiotic resistance.

 

41. Please continue to think about your older adult family member who lives in a nursing home and who is under your care. Please indicate the extent to which you agree with the following statements, from strongly disagree to strongly agree. 

Perceived Barriers to Using Antibiotics Appropriately	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
If my healthcare professional told my family member to wait a few days to see if they feel better before prescribing antibiotics, they would feel inconvenienced.
If my healthcare professional told my family member, they didn’t need antibiotics for their respiratory infection, I would feel worried that they wouldn’t feel better.
If my healthcare professional told my family member, they didn’t need antibiotics for their respiratory infection, I would feel worried that they might get sicker.

42. Please think about your older adult family member who lives in a nursing home and who is under your care. Please indicate your level of confidence for each of the following questions. 

Self-Efficacy	Not at all Confident	Somewhat Confident	Moderately Confident	Confident	Very Confident
When your family member has a viral infection, how confident are you that they do not need antibiotics to treat the infection?
How confident are you in your ability to discuss your questions and concerns about your family member’s antibiotic use with their healthcare professional?
How confident are you that you can accept your family member’s healthcare professional’s recommendation if they say that they do not need antibiotics?

43. Please continue to think about your older adult family member who lives in a nursing home and who is under your care. Please indicate the extent to which you agree with the following statements, from strongly disagree to strongly agree. 

Perceived importance of discussing appropriate antibiotic use with HCPs	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
When my family member is sick, it is important to talk with their healthcare professional(s) about what the best treatment is for their illness.
When my family member is sick, but antibiotics are not needed, it is important to talk with their healthcare professionals about other ways to feel better.
When my family member is sick and antibiotics can help, it is important to talk with their healthcare professional(s) about the risks of taking antibiotics (e.g., side effects, antibiotic resistance).
When my family member is sick and antibiotics can help, it is important to talk with their healthcare professional(s) about the benefits of taking antibiotics.

Behavior [ALL EXCEPT FAMILY CAREGIVER]

Programmer: Include one question per page.

44. Think about the visits you had with a healthcare professional for a respiratory infection over the past 12 months. These include both in-person and telehealth visits. During these visits, how often did you speak with your healthcare professional(s) about the following?

Programmer: Include "Did not visit healthcare professional for a respiratory infection in the past 12 months” as one option for all of a–d (merged cell).

	Never	Rarely	Sometimes	Often	Always	Do not know/cannot recall	Did not visit healthcare professional for an infection in the past 12 months
If antibiotics were or were not needed to treat my infection.
How to feel better when I was sick without taking antibiotics.
The risks of taking an antibiotic (e.g., antibiotic resistance, side effects) when I was sick.
The benefits of taking antibiotics when I was sick.

Programmer: If response to Q44 a, b, c, and d is “Did not visit healthcare professional for an infection in the past 12 months”, skip to Q60 (SOURCES OF INFORMATION). For any other response, proceed to Q45.

45. In the past 12 months, how often have you expected—but not directly asked—a healthcare professional to prescribe you antibiotics?

• Always

• Often

• Sometimes

• Rarely

• Never

• Do not know/cannot recall

46. In the past 12 months, did you expect – but not directly ask for -- a healthcare professional to prescribe you antibiotics because you had COVID-19?

• Yes, I had COVID-19 and expected antibiotics

• No, I had COVID-19 but did not expect antibiotics

• No, I have not had COVID-19 in the past 12 months

• Do not know/cannot recall

47. In the past 12 months, how often have you directly asked a healthcare professional to prescribe you antibiotics?

• Always

• Often

• Sometimes

• Rarely

• Never

• Do not know/cannot recall

48. In the past 12 months, did you directly ask a healthcare professional to prescribe you antibiotics because you had COVID-19?

• Yes, I had COVID-19 and directly asked a healthcare professional to prescribe antibiotics

• No, I had COVID-19 but did not directly ask a healthcare professional to prescribe antibiotics

• No, I have not had COVID-19 in the past 12 months

• Do not know/cannot recall

49. In the past 12 months, did a healthcare professional prescribe you antibiotics?

• Yes

• No

• Do not know/cannot recall

50. In the past 12 months, did a healthcare professional prescribe you antibiotics because you had COVID-19?

Programmer: For Q50, if the respondent selects, “I did not take the antibiotics at all” or “Do not know/cannot recall,” do not allow them to select the other responses.

• Yes

• No

• I did not take antibiotics at all

• Do not know/cannot recall

• I have not had COVID-19 in the past 12 months

51. In the past 12 months, did you ever take leftover antibiotics previously prescribed to you or someone else by a healthcare professional?

Programmer: For Q51, if the respondent selects, “No, I did not take leftover antibiotics previously prescribed to me or someone else” or “Do not know/cannot remember”, do not allow them to select the other responses.

• Yes, I took leftover antibiotics previously prescribed to me

• Yes, I took leftover antibiotics previously prescribed to someone else

• No, I did not take leftover antibiotics previously prescribed to me or someone else

• Do not know/cannot remember

• Not applicable/I was not sick during this time

52. In the past 12 months, did you ever take leftover antibiotics previously prescribed to you or someone else by a healthcare professional because you had COVID-19?

Programmer: For Q52, if the respondent selects, “No, I did not take leftover antibiotics previously prescribed to me or someone else” or “Do not know/cannot remember”, do not allow them to select the other responses.

• Yes, I took leftover antibiotics previously prescribed to me because I had COVID-19

• Yes, I took leftover antibiotics previously prescribed to someone else because I had COVID-19

• No, I did not take leftover antibiotics previously prescribed to me or someone else

• Do not know/cannot remember

• I did not test positive for COVID-19 in the past 12 months

Behavior [FOR FAMILY CAREGIVER] 

53. Think about the visits you had with a healthcare professional for your older adult family member who lives in a nursing home and who is under your care for a respiratory infection over the past 12 months. During these visits, how often did you speak with your healthcare professional(s) about the following? 

	Never	Rarely	Sometimes	Often	Always	Do not know/cannot recall	My family member did not have a respiratory infection that may require an antibiotic in the past 12 months
Whether or not antibiotics were needed to treat my family member’s infection.
How to make my family member feel better when they were sick, without taking antibiotics.
The risks of taking antibiotics (e.g., antibiotic resistance, side effects) when my family member was sick.
The benefits of my family member taking antibiotics when they were sick.

Programmer: If response to Q53 a, b, c, and d is “Did not visit healthcare professional for a respiratory infection in the past 12 months”, skip to Q60 (SOURCES OF INFORMATION).

54. In the past 12 months, how often have you expected—but not directly asked—a healthcare professional to prescribe your family member antibiotics? 

• Always 

• Often 

• Sometimes 

• Rarely 

• Never 

• Do not know/cannot recall 

55. In the past 12 months, did you expect - but not directly ask for - a healthcare professional to prescribe antibiotics to your family member because they had COVID-19?  

• Yes, my family member had COVID-19 and I expected the healthcare professional to prescribe antibiotics.

• No, my family member had COVID-19 but I did not expect the healthcare professional to prescribe antibiotics.

• No, my family member did not have COVID-19 in the past 12 months.

• Do not know/cannot recall

56. In the past 12 months, how often have you directly asked a healthcare professional to prescribe your family member antibiotics?

• Always

• Often

• Sometimes

• Rarely

• Never

• Do not know/cannot recall

57. In the past 12 months, did you directly ask a healthcare professional to prescribe your family member antibiotics because they had COVID-19?

• Yes, my family member had COVID-19 and I directly asked the healthcare professional to prescribe antibiotics.

• No, my family member had COVID-19 but I did not directly ask the healthcare professional to prescribe antibiotics.

• No, my family member did not have COVID-19 in the past 12 months.

• Do not know/cannot recall

58. In the past 12 months, did a healthcare professional prescribe your family member antibiotics? 

• Yes 

• No 

• Do not know/cannot recall 

59. In the past 12 months, did a healthcare professional prescribe your family member antibiotics because they tested positive for COVID-19? 

• Yes 

• No 

• Do not know/cannot recall 

• My family member did not test positive for COVID-19 in the past 12 months

• Not applicable/they were

Sources of Information [ALL]

60. To whom or where do you go to learn about antibiotic use? Select all that apply.

Programmer: Rotate response options; keep the placement of “Other” and “I have not tried to learn about antibiotic use” as is.

• My doctor/healthcare professional

• Pharmacist

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

• Centers for Disease Control and Prevention (CDC) website

• Health magazines (e.g., Women’s Health, Men’s Health, Prevention), please specify: ______________________________

• Family members and/or friends

• Newspapers, please specify: ___________________________

• Television, please specify: ___________________________

• Radio, please specify: _____________________________

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

• Other, please specify: ______________________________

• I have not tried to learn about antibiotic use

Programmer: If the response to Q60 is, “I have not tried to learn about antibiotic use”, do not allow them to select other responses.

61. If you need to get information about appropriate antibiotic use, where would you prefer to get it? Select all that apply.

• My doctor/healthcare professional

• Pharmacist

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

• Centers for Disease Control and Prevention (CDC) website or materials

• Health magazines (e.g., Women’s Health, Men’s Health, Prevention), please specify: _______________

• Family members and/or friends

• Other 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, Twitter, Instagram, LinkedIn, etc.), please specify: __________________________

• Podcasts, please specify: ____________________________

• Blogs, please specify: ______________________________

• Other, please specify: _________________________________

• I do not need to get information about appropriate antibiotic use

• Do not know/unsure

62. Did you know that CDC’s Be Antibiotics Aware campaign has resources you can use to learn about antibiotic use?

• Yes

• No

Programmer: If the respondent selects “Yes” to Q62, proceed to Q63. If the respondent selects “No” to Q62, skip Q63 and proceed to DEMOGRAPHIC CHARACTERISTICS section.

63. How did you learn about CDC’s Be Antibiotics Aware resources? Select all that apply.

Programmer: Rotate response options; keep placement of “Other” and “Do not know” as is.

• Fact sheets/handouts at my doctor/healthcare professional’s office

• Poster at my doctor/healthcare professional's office

• PSA (public service announcement) video at my doctor/healthcare professional's office

• Pharmacist

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

• Centers for Disease Control and Prevention (CDC) website

• Family members and/or friends

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

• Other, please specify: __________________________

• Do not know/cannot recall

Programmer: If response to Q63 is “Do not know/cannot recall,” do not allow them to select other responses.

Demographic Characteristics [ALL]

Thank you. Now we would like to know more about you.

64. What is your ethnicity?

• Hispanic or Latino

• Not Hispanic or Latino

65. What is your race?

• American Indian or Alaska Native

• Asian  

• Black or African American  

• Native Hawaiian or Other Pacific Islander  

• White 

66. What is the highest degree you have received? Please select only one.

Programmer: If a respondent selects “Prefer not to answer” do not allow them to select other responses.

• 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

End of Survey Message

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

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-XXXX