Attachment D: GAOS Consumer Post-Campaign Screener and Survey
Form Approved
OMB No. 0920-XXX
Expiration Date XX/XX/XXXX
Cancer patients and their caregivers
Patients who survived severe COVID-19 or sepsis and their caregivers
Parents of children 12 and younger
Adults who care for a family member age 65+
Men aged 65+ with one or more chronic conditions
Healthy adults 65+
Hide all subheadings of sections and questions from respondents.
Hide all programmer’s instructions from respondents.
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.”
Terminate also means ineligible.
Terminate all eligible respondents immediately.
Present the “Ineligibility Message” whenever a response terminates the survey.
Thank you for participating in this survey. The results of this survey will help the Centers for Disease Control and Prevention (CDC) refine and improve its ongoing campaign promoting early recognition and timely treatment of sepsis.
Programmer: Include one question per page. Screener should terminate as soon as the respondent selects an option that deems him/her ineligible.
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.
In what ZIP Code and State do you live? _____________________
Programmer: Targeted states include Illinois (IL), Louisiana (LA), and New York (NY)
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.
How old are you? _ _ years
Prefer not to answer [INELIGIBLE/TERMINATE]
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.
What sex were you assigned at birth, on your original birth certificate?
Male
Female
Refused
I don’t know
Do you currently describe yourself as male, female, transgender?
Male
Female
Transgender
None of these
Are you currently the primary caregiver for a family member aged 65 years or older?
Yes
No
Programmer: If the respondent selects “Yes” to Q6 and age is between 18-64 years of age in Q3, categorize the respondent as “Adults who care for a family member age 65+ years.”
Are you the parent of at least one child who is 12 years old or younger?
Yes
No
Programmer: If the respondent selects “Yes” to Q7, proceed to Q8, else skip Q8.
Who in your family usually makes the healthcare decisions about your child(ren) who is(are) age 12 or younger regardless of where the child resides?
Self
Self and spouse/partner together
Someone else
Programmer: If the respondent selects “Self” or “Self and spouse/partner together” and he/she is between 18-64 years of age, categorize respondent as “Parent of children 12 years or younger,” then proceed to Q9. If the respondent selects, “Someone else,” do not categorize but proceed to Q9.
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
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
Have you ever been hospitalized due to COVID-19?
Yes
No
Programmer: If the respondent selects “Yes,” categorize respondent as “COVID-19 survivor.”
Are you currently the primary caregiver for someone who was hospitalized due to COVID-19?
Yes
No
Programmer: If the respondent selects “Yes,” categorize respondent as “Caretaker of COVID-19 survivor.”
Has a healthcare professional ever diagnosed you with sepsis?
Yes
No
Programmer: If the respondent selects “Yes,” categorize respondent as “Sepsis survivor.”
Are you currently the primary caregiver for someone who is a sepsis survivor or was diagnosed with sepsis by a healthcare professional?
Yes
No
Programmer: If the respondent selects “Yes,” categorize respondent as “Caretaker of sepsis survivor.”
Has a healthcare professional ever diagnosed you with cancer?
Yes
No
Programmer: If the respondent selects “Yes” to Q15, proceed to Q16 else skip Q16.
Are you currently receiving treatment or recently completed treatment for cancer (e.g., chemotherapy, radiation, surgery, etc.)?
Yes
No
Programmer: If the respondent selects “Yes” to both Q15 and Q16, categorize respondent as “Cancer patient.”
Are you currently the primary caregiver for someone who is a cancer patient or was diagnosed with cancer by a healthcare professional?
Yes
No
Programmer: If the respondent selects “Yes” to Q17, proceed to Q18, else skip Q18.
Are you currently the primary caregiver for someone who is currently receiving treatment for cancer or who in the past 12 months, completed treatment for cancer (e.g., chemotherapy, radiation, surgery, etc.)?
Yes
No
Programmer: If the respondent selects “Yes” to Q17 and/or Q18, categorize respondent as “Caregiver of a cancer patient.”
Has a healthcare professional ever diagnosed you with a chronic medical condition (e.g., diabetes, lung disease, cancer, kidney disease, etc.)?
Yes
No
Do not know [INELIGIBLE]
Programmer: If the respondent selects “No” to Q19, skip Q20, else proceed to Q20 if “Yes.”
Has a healthcare professional ever told you that you have one of the following chronic medical conditions? Select all that apply.
Arthritis
Chronic lung disease
Diabetes
Heart disease
Immunosuppression (weakened immune system)
Kidney disease
Lung disease
Stroke
OTHER: __________________
None of the above [INELIGIBLE]
Programmer: Do not allow respondents who select “None of the above” to select any other response.
Programmer: If the respondent selects “No” to Q19, and 65+ years of age, categorize respondent as “Healthy adults 65+”
Programmer: If respondent selects “None of the above,” TERMINATE.
If respondent selects “Arthritis,” “Cancer,” “Kidney disease,” “Chronic lung disease,” “Diabetes,” “Heart disease,” “Immunosuppression,” “Other,” and/or “Stroke” and is 65+ years of age, and male, categorize respondent as “Men 65+ with one or more chronic conditions.”
Programmer: If the respondent selects “Yes” to Q15 and/or Q16, skip Q21.
How would you rate your overall physical health?
Excellent
Very good
Good
Fair
Poor
Do you, your spouse/partner, or any other member of your household currently or in the past work for/as:
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Programmer: If the respondent selects “Yes” to any of the options, TERMINATE, else ELIGIBLE.
Programmer:
Categorize respondent as “Adults who care for a family member age 65+ years
Q3 = 18-64 AND
Q6 = Yes AND
Q9 = English AND
Q10 = English
Categorize respondent as “Parents of children ≤ 12 years
Q3 = 18-64 AND
Q7 = Yes AND
Q8 = Self or Self and spouse/partner together AND
Q9 = English AND
Q10 = English
Categorize respondent as “Patients who survived severe Covid-19
Q11 = Yes AND
Q9 = English AND
Q10 = English
Categorize respondent as “Caregivers of Patients who survived severe Covid-19”
Q12 = Yes AND
Q9 = English AND
Q10 = English
Categorize respondent as “Patients who survived sepsis”
Q13 = Yes AND
Q9 = English AND
Q10 = English
Categorize respondent as “Caregivers of Patients who survived sepsis”
Q14 = Yes AND
Q9 = English AND
Q10 = English
Categorize respondent as “Cancer patients”
Q15 = Yes AND
Q16 = Yes AND
Q9 = English AND
Q10 = English
Categorize respondent as “Caregivers of Cancer patients”
Q17 = Yes AND/OR
Q18 = Yes AND
Q9 = English AND
Q10 = English
Categorize respondent as “Healthy adults 65+”
Q3 = 65+ AND
Q19 = No AND
Q9 = English AND
Q10 = English
Categorize respondent as “Men aged 65+ with one or more chronic conditions ”
Q3 = 65+ AND
Q5 = Male AND
Q19 = Yes AND/OR
Q20 = Arthritis, Cancer, Chronic kidney disease, Chronic lung disease, Diabetes, Heart disease, Immunosuppression, Other, and/or Stroke
Q9 = English AND
Q10 = English
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.”
Thank you for answering the screening questions. We have determined that you are eligible to proceed to with this survey. If you have any questions, please contact [name] at [email] or call phone number [number] or [number].
Please click on “Proceed to Survey” and answer the questions to the best of your ability.
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] or call phone number [number] or [number].
Thank you for your time. Please click on “Exit Survey” to exit.
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 2-3 months.
Please indicate below whether you have seen or heard any of the following campaign names or slogans in the past 2-3 months.
Programmer: Rotate Q23 (a - e), the column named “Campaigns” among respondents.
Campaigns |
Yes |
No |
Do not know/cannot recall |
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I
n
the past 2-3 months, have you heard this slogan and/or seen this
logo?
Yes
No
Do not know/cannot recall
Programmer: If the respondent selects “Yes” to Q23d and “Yes” or “Do not know/cannot recall to Q24, classify as “Exposed” and proceed to the FREQUENCY AND CHANNEL OF EXPOSURE section.
If the respondent selects “Do not know/cannot recall” to Q23d and “Yes” to Q24, 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 Q23d and “No” or “Do not know/cannot recall” to Q24, classify as “Unexposed” and proceed to the KNOWLEDGE section. After the quota of unexposed has been met for each target group then TERMINATE.
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 2-3 months.
In the past 2-3 months, approximately how often did you see CDC’s Get Ahead of Sepsis 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 |
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Fact sheet |
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Brochure |
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Graphic |
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Newspaper/magazine advertisement |
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Flyer |
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Other print media, please specify: ______________________
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In the past 2-3 months, approximately how often did you see CDC’s Get Ahead of Sepsis 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 |
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YouTube |
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Other social media, please specify: ______________________
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In the past 2-3 months, approximately how often did you see CDC’s Get Ahead of Sepsis campaign messages, campaign name, or logo on …?
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) |
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Website advertisements |
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Online news articles |
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Streaming TV/video services (e.g., Hulu, Netflix, [Amazon] Prime Video) |
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Streaming Internet radio |
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Blogs |
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Search engines (e.g., Google) |
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Other websites, please specify: ______________________
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In the past 2-3 months, approximately how often did you see CDC’s Get Ahead of Sepsis campaign messages, campaign name, or logo on …?
Programmer: Rotate the media options (TV and Radio Media).
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) |
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Broadcast radio |
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Other media formats, please specify: ______________________
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In the past 2-3 months, approximately how often did you see CDC’s Get Ahead of Sepsis campaign messages, campaign name, or logo in …?
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 |
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Bus, train, or subway stations |
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On buses or taxi cabs |
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Advertisement in mall |
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Advertisement in a grocery store |
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Advertisement in a store pharmacy |
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Advertisement at a shopping center or parking lot |
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Other public locations, please specify: ______________________
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In the past 2-3 months, approximately how often did you see CDC’s Get Ahead of Sepsis campaign messages, campaign name, or logo in …?
Programmer: Rotate the media options (Healthcare Settings).
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 |
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Other healthcare locations, please specify: ______________________
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In the past 2-3 months, approximately how often did you see CDC’s Get Ahead of Sepsis 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 |
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Podcast |
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Webcasts or webinars |
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Live events |
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Other media, please specify: ______________________
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Programmer: If the respondent selects “Never” and/or “Do not know/cannot recall” as responses to ALL options from Q25 - Q31, proceed with Q32 (open-ended question), else skip Q32.
You indicated that you saw or heard the campaign name, Get Ahead of Sepsis, or saw the campaign logo in the past 2-3 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 Q25-Q31, and left Q32 blank, reclassify these respondents as “Unexposed” and proceed to KNOWLEDGE section.
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 Q25-Q31 and filled in Q32 with more than just N/A or NONE, classify as “Exposed” and proceed to KNOWLEDGE section.
Programmer: Include one question per page. RIGHT/WRONG responses have been indicated but do not disclose to respondents.
Sepsis is defined as the following:
Programmer: Rotate response options; keep the placement of “None of the above,” “All of the above,” and “Do not know” as is.
A chronic condition that primarily affects kidney function [WRONG]
The body’s extreme response to an infection [RIGHT]
A neurological disorder resulting from the flu [WRONG]
Contagious illness that commonly peaks in the winter [WRONG]
All of the above [WRONG]
None of the above [WRONG]
Do not know [WRONG]
Sepsis is a medical emergency.
TRUE [RIGHT]
FALSE [WRONG]
Anyone can get an infection, and almost any infection, including COVID-19, can lead to sepsis.
TRUE [RIGHT]
FALSE [WRONG]
Infections do not put you or your loved one at risk for a life-threatening condition called sepsis.
TRUE [WRONG]
FALSE [RIGHT]
When germs get into a person’s body, they can cause an infection. If that infection is not stopped, it can cause sepsis.
TRUE [RIGHT]
FALSE [WRONG]
Which of the following types of infections, if any, are OFTEN linked with sepsis? Select all that apply.
Programmer: Rotate response options; keep placement of “None of the above,” “All of the above,” and “Do not know” as is.
Ear [WRONG]
Skin [RIGHT]
Lung [RIGHT]
Eye [WRONG]
Urinary tract [RIGHT]
Nail [WRONG]
Gastrointestinal tract [RIGHT]
Severe COVID-19 [RIGHT]
All of the above [WRONG]
None of the above [WRONG]
Do not know [WRONG]
Which of the following groups of individuals are at higher risk for developing infections than can lead to sepsis? Select all that apply.
Programmer: Rotate response options; keep placement of “None of the above,” “All of the above,” and “Do not know” as is.
Adults 65 or older [RIGHT]
People with weakened immune systems [RIGHT]
People with chronic medical conditions, such as diabetes, lung disease, cancer, and kidney disease [RIGHT]
Children younger than one year old [RIGHT]
People who have previously survived sepsis [RIGHT]
People with recent severe illness or hospitalization [RIGHT]
Adults with no underlying conditions between the ages of 20 and 35 years [WRONG]
Do not know [WRONG]
None of the above [WRONG]
Programmer: If respondent selects “All of the above,” “Do not know,” or “None of the above,” do not allow them to select other responses.
Check all the signs and symptoms of sepsis below:
Programmer: Rotate response options; keep placement of “I do not know any of the signs and symptoms of sepsis”
Excessive hunger [WRONG]
Clammy or sweaty skin [RIGHT]
Confusion or disorientation [RIGHT]
Extreme pain or discomfort [RIGHT]
Fever, shivering, or feeling very cold [RIGHT]
High heart rate or low blood pressure [RIGHT]
Shortness of breath [RIGHT]
I do not know any of the signs and symptoms of sepsis. [WRONG]
Programmer: If respondent selects “I do not know any of the signs and symptoms of sepsis,” do not allow them to select other responses.
If you or your loved one has an infection that is not getting better or is getting worse, you should ACT FAST and get medical care IMMEDIATELY.
Yes [RIGHT]
No [WRONG]
Which of the following activities, if any, should you do to prevent infections that can lead to sepsis? Select all that apply.
Programmer: Rotate response options; keep placement of “None of the above,” “All of the above,” and “Do not know” as is.
Regular handwashing [RIGHT]
Showering twice daily [WRONG]
Getting recommended vaccines [RIGHT]
Avoiding public restrooms [WRONG]
Keeping cuts and wounds clean and covered until healed [RIGHT]
Taking good care of chronic conditions [RIGHT]
All of the above [WRONG]
None of the above [WRONG]
Do not know [WRONG]
Programmer: If respondent selects “All of the above” or “None of the above,” do not allow them to select other responses.
Programmer: Include one question per page. Do not allow participants to go back and change their answer to a previous question. NOTE**Subheadings within all tables should not be visible to respondents.
Programmer: Use the following section for “Caregivers of cancer patients.”
Next, we are going to ask you some questions to learn more about your perspective on infections and sepsis about family members. Please give us your honest responses.
We would like to provide you with a definition for sepsis to assist you in answering the following questions:
Anyone can get an infection, and almost any infection, including COVID-19, can lead to sepsis. Sepsis is the body’s extreme response to an infection. It is a life-threatening medical emergency. Sepsis happens when an infection you already have triggers a chain reaction throughout your body. Infections that lead to sepsis most often start in the lung, urinary tract, skin, or gastrointestinal tract. Without timely treatment, sepsis can rapidly lead to tissue damage, organ failure, and death.
Please answer the following questions about the cancer patient(s) 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.
43. [Perceived Susceptibility] |
Strongly Disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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44. [Perceived Severity] |
Strongly Disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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45. [Perceived Benefits] |
Strongly Disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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46. [Self-Efficacy] |
Strongly Disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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Programmer: Include one question per page. Do not allow participants to go back and change their answer to a previous question. NOTE**Subheadings within all tables should not be visible to respondents.
Programmer: Use the following section for “Cancer patients.”
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.
We would like to provide you with a definition for sepsis to assist you in answering the following questions:
Anyone can get an infection, and almost any infection, including COVID-19, can lead to sepsis. Sepsis is the body’s extreme response to an infection. It is a life-threatening medical emergency. Sepsis happens when an infection you already have triggers a chain reaction throughout your body. Infections that lead to sepsis most often start in the lung, urinary tract, skin, or gastrointestinal tract. 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.
47.[Perceived Susceptibility] |
Strongly Disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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48. [Perceived Severity] |
Strongly Disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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49. [Perceived Benefits] |
Strongly Disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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50. [Self-Efficacy] |
Strongly Disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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Programmer: Include one question per page. Do not allow participants to go back and change their answer to a previous question. NOTE**Subheadings within all tables should not be visible to respondents.
Programmer: Use the following section for “Caregivers of sepsis or severe Covid-19 survivors.”
Next, we are going to ask you some questions to learn more about your perspective on infections and sepsis about family members. Please give us your honest responses.
We would like to provide you with a definition for sepsis to assist you in answering the following questions:
Anyone can get an infection, and almost any infection, including COVID-19, can lead to sepsis. Sepsis is the body’s extreme response to an infection. It is a life-threatening medical emergency. Sepsis happens when an infection you already have triggers a chain reaction throughout your body. Infections that lead to sepsis most often start in the lung, urinary tract, skin, or gastrointestinal tract. Without timely treatment, sepsis can rapidly lead to tissue damage, organ failure, and death.
Please answer the following questions about the sepsis or severe Covid-19 survivor(s) 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.
51.[Perceived Susceptibility] |
Strongly Disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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52. [Perceived Severity] |
Strongly Disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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53. [Perceived Benefits] |
Strongly Disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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54.[Self-Efficacy] |
Strongly Disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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Programmer: Include one question per page. Do not allow participants to go back and change their answer to a previous question. NOTE**Subheadings within all tables should not be visible to respondents.
Programmer: Use the following section for “Sepsis or severe COVID-19 survivors.”
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.
We would like to provide you with a definition for sepsis to assist you in answering the following questions:
Anyone can get an infection, and almost any infection, including COVID-19, can lead to sepsis. Sepsis is the body’s extreme response to an infection. It is a life-threatening medical emergency. Sepsis happens when an infection you already have triggers a chain reaction throughout your body. Infections that lead to sepsis most often start in the lung, urinary tract, skin, or gastrointestinal tract. 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.
55. [Perceived Susceptibility] |
Strongly Disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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56. [Perceived Severity] |
Strongly Disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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57.[Perceived Benefits] |
Strongly Disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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58. [Self-Efficacy] |
Strongly Disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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Programmer: Include one question per page. Do not allow participants to go back and change their answer to a previous question. NOTE**Subheadings within all tables should not be visible to respondents.
Programmer: Use the following section for “Parent of children ≤ 12 years old.”
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.
We would like to provide you with a definition for sepsis to assist you in answering the following questions:
Anyone can get an infection, and almost any infection, including COVID-19, can lead to sepsis. Sepsis is the body’s extreme response to an infection. It is a life-threatening medical emergency. Sepsis happens when an infection you already have triggers a chain reaction throughout your body. Infections that lead to sepsis most often start in the lung, urinary tract, skin, or gastrointestinal tract. 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 healthcare decisions and indicate the extent to which you agree with the following statements, from strongly disagree to strongly agree.
59.[Perceived Susceptibility] |
Strongly Disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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60. [Perceived Severity] |
Strongly Disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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61. [Perceived Benefits] |
Strongly Disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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62. [Self-Efficacy] |
Strongly Disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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Programmer: Include one question per page. Do not allow participants to go back and change their answer to a previous question. NOTE**Subheadings within all tables should not be visible to respondents.
Programmer: Use the following section for “Adults who care for a family member age 65+."
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.
We would like to provide you with a definition for sepsis to assist you in answering the following questions:
Anyone can get an infection, and almost any infection, including COVID-19, can lead to sepsis. Sepsis is the body’s extreme response to an infection. It is a life-threatening medical emergency. Sepsis happens when an infection you already have triggers a chain reaction throughout your body. Infections that lead to sepsis most often start in the lung, urinary tract, skin, or gastrointestinal tract. Without timely treatment, sepsis can rapidly lead to tissue damage, organ failure, and death.
Please answer the following questions about the FAMILY MEMBER AGED 65 YEARS OR OLDER (family member) 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.
63. [Perceived Susceptibility] |
Strongly Disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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64. [Perceived Severity] |
Strongly Disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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65. [Perceived Benefits] |
Strongly Disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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66. [Self-Efficacy] |
Strongly Disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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Programmer: Include one question per page. Do not allow participants to go back and change their answer to a previous question. NOTE**Subheadings within all tables should not be visible to respondents.
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.
We would like to provide you with a definition for sepsis to assist you in answering the following questions:
Anyone can get an infection, and almost any infection, including COVID-19, can lead to sepsis. Sepsis is the body’s extreme response to an infection. It is a life-threatening medical emergency. Sepsis happens when an infection you already have triggers a chain reaction throughout your body. Infections that lead to sepsis most often start in the lung, urinary tract, skin, or gastrointestinal tract. 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.
Programmer: Do not show Q69a to Health adults 65+. Show to “Men 65+ with one or more chronic conditions.”
67.[Perceived Susceptibility] |
Strongly Disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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68. [Perceived Severity] |
Strongly disagree |
Disagree |
Neutral |
Agree |
Strongly agree |
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69. [Perceived Benefits] |
Strongly disagree |
Disagree |
Neutral |
Agree |
Strongly agree |
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70. [Self-Efficacy] |
Strongly disagree |
Disagree |
Neutral |
Agree |
Strongly agree |
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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 “Caregivers of a cancer patient.”
Please answer the following questions about the Cancer patient(s) for whom you are currently the primary caregiver.
71. In the past 2-3 months, how often did you speak with the healthcare professionals of the cancer patient(s) you care for, or help them to speak with their healthcare professionals about the following?
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Never |
Rarely |
Sometimes |
Often |
Always |
Do
not know/ |
Did not visit a healthcare professional in past 2-3 months |
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72. What are the barriers that make it hard for you to have conversations/help the cancer patient(s) you care for have conversations about how to prevent infections that can lead to 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 problem for the cancer patient(s) I care for.
I do not think infections that can lead to sepsis are a big problem for the cancer patient(s) I care for.
The cancer patient(s) I care for does not have a healthcare professional 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
73. Did the cancer patient(s) you care for get a flu vaccine for the 2022-2023 flu season?
Yes
No
Do not know
What are the barriers that make it hard for you to prevent infections that can lead to sepsis in the cancer patient(s) you care for? Select all that apply.
I am not able to get to a doctor with the cancer patient(s) I care for, to discuss the steps needed to prevent infections that can lead to sepsis.
I am afraid to see a doctor or nurse with the cancer patient(s) I care for because I am worried about getting COVID-19 or the cancer patient getting COVID-19.
I am not able to access or afford supplies for cuts and wound care that I would need to prevent infections that can lead to sepsis for the cancer patient(s) I care for.
I am not familiar enough with how to prevent infections that can lead to sepsis in the cancer patient(s) I care for.
I do not know if the cancer patient(s) I care for need to get any vaccinations.
I do not want the cancer patient(s) I care for to get vaccinations.
I do not think it is possible for me to prevent infections that can lead to sepsis in the cancer patient(s) I care for.
I do not think sepsis is a problem for the cancer patient(s) I care for.
I do not think infections that can lead to sepsis are a problem for the cancer patient(s) I care for.
I do not think it is important to prevent infections that can lead to sepsis in the cancer patient(s) I care for.
I do not have time to take all the steps needed to prevent infections that can lead to sepsis in the cancer patient(s) I care for.
The health of the cancer patient(s) I care for makes it hard for me to take all the steps needed to prevent infections that can lead to sepsis.
I’m not confident the healthcare system in the area where the cancer patient(s) I care for reside can respond correctly to sepsis.
I’m not confident the healthcare professionals in the area where the cancer patient(s) I care for reside can respond correctly to sepsis.
The cancer patient(s) I care for lives very far from healthcare services.
The cancer patient(s) I care for does not have easy access to healthcare services.
The cancer patient(s) I care for relies on telehealth services.
Other, please explain: ____________________________________________________________
I have not encountered any barriers to preventing infections that can lead to sepsis in the cancer patient(s) I care for.
I do not try to prevent infections that can lead to sepsis in the cancer patient(s) I care for.
Do not know/cannot recall
Prefer not to answer
In the last 2-3 months, have you looked for information about infections that can lead to sepsis for the cancer patient(s) you care for?
Yes
No
Do not know/cannot recall
Programmer: If the respondent selects “Yes” to Q76, proceed to “SOURCES OF INFORMATION” section, else skip “SOURCES OF INFORMATION” section.
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 “Cancer patients”.
Think about the visits you have had with healthcare professionals over the past 2-3 months. These include both in-person and telehealth visits. During these visits, how often did you speak with your healthcare professionals about the following?
Programmer: Include “Did not visit a healthcare professional for an illness in the past 2-3 months” as one option for all of a–f (merged cell).
|
Never |
Rarely |
Sometimes |
Often |
Always |
Do
not know/ |
Did not visit a healthcare professional in past 2-3 months |
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What are the barriers that make it hard for you to have conversations with your healthcare professional about how to prevent infections that can lead to sepsis? Select all that apply.
Programmer: Rotate response options; keep the placement of “Do not know/cannot recall,” “Prefer not to answer,” “Other,” and “I do not have any barriers to having conversations about these topics” as is.
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 problem for me.
I do not think infections that can lead to sepsis are a problem for me.
I do not have a healthcare professional 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
Programmer: If respondent selects “I do not have any barriers to having conversations about these topics,” “Do not know/cannot recall” or “Prefer not to answer,” do not allow them to select other responses.
Did you get a flu vaccine for the 2022-2023 flu season?
Yes
No
What are the barriers that make it hard for you to prevent infections that can lead to sepsis? Select all that apply.
Programmer: Rotate response options; keep the placement of “Don’t know/cannot recall,” “Prefer not to answer,” “Other,” “I do no try to prevent infections…,” and “I have not encountered any barriers to preventing infection…” as is.
I am not able to get to a doctor or nurse to discuss the steps needed to prevent infections that can lead to sepsis.
I am afraid to see a doctor or nurse because I am worried about getting COVID-19.
I am not able to access or afford supplies for cuts and wound care that I would need to prevent infections that can lead to sepsis.
I am not familiar enough with how to prevent infections that can lead to 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.
I do not think sepsis is a problem for me.
I do not think infections that can lead to sepsis are a problem for me.
I do not think it is important to prevent infections that can lead to sepsis.
I do not have time to take all the steps needed to prevent infections that can lead to sepsis.
My health makes it hard for me to take all the steps needed to prevent infections that can lead to sepsis.
I’m not confident the healthcare system in my area can respond correctly to sepsis.
I’m not confident the healthcare professionals in my area can respond correctly to sepsis.
I live very far from healthcare services.
I don’t have easy access to healthcare services.
I rely on telehealth services.
Other, please explain: ________________________________________________________
I have not encountered any barriers to preventing infections that can lead to sepsis.
I do not try to prevent infections that can lead to sepsis.
Do not know/cannot recall
Prefer not to answer
Programmer: If respondent selects “I have not encountered any barriers to preventing infections that can lead to sepsis,” “I do not try to prevent infections that lead to sepsis,” “Do not know/cannot recall” or “Prefer not to answer,” do not allow them to select other responses.
In the last 2-3 months, have you looked for information about infections that can lead to sepsis?
Yes
No
Do not know/cannot recall
Programmer: If the respondent selects “Yes” to Q81, proceed to “SOURCES OF INFORMATION” section, else skip “SOURCES OF INFORMATION” section.
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 “Caregivers of Sepsis or Severe Covid-19 Survivor.”
Please answer the following questions about the survivor(s) of sepsis or severe COVID-19 for whom you are currently the primary caregiver.
In the past 2-3 months, how often did you speak with healthcare professionals of the survivor of sepsis or severe COVID-19 you care for, or help them to speak with their healthcare professionals about the following?
|
Never |
Rarely |
Sometimes |
Often |
Always |
Do
not know/ |
Did not visit a healthcare professional in past 2-3 months |
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What are the barriers that make it hard for you to have conversations/help the survivor of sepsis or severe COVID-19 you care for have conversations about how to prevent infections that can lead to 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 problem for the sepsis or severe COVID-19 survivor I care for.
I do not think infections that can lead to sepsis are a problem for the sepsis or severe COVID-19 survivor I care for.
The sepsis or severe COVID-19 survivor I care for does not have a healthcare professional 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
Did the sepsis or severe COVID-19 survivor you care for get a flu vaccine for the 2022-2023 flu season?
Yes
No
Do not know
What are the barriers that make it hard for you to prevent infections that can lead to sepsis in the survivor of sepsis or severe COVID-19 you care for? Select all that apply.
I am not able to get to a doctor with the survivor of sepsis or severe COVID-19 I care for to discuss the steps needed to prevent infections that can lead to sepsis.
I am afraid to see a doctor or nurse with the survivor of sepsis or severe COVID-19 I care for because I am worried about getting COVID-19 or the survivor of sepsis or severe COVID-19 getting COVID-19.
I am not able to access or afford supplies for cuts and wound care that I would need to prevent infections that can lead to sepsis for the survivor of sepsis or severe COVID-19 I care for.
I am not familiar enough with how to prevent infections that can lead to sepsis in the survivor of sepsis or severe COVID-19 I care for.
I do not know if the survivor of sepsis or severe COVID-19 I care for needs to get any vaccinations.
I do not want the survivor of sepsis or severe COVID-19 I care for to get vaccinations.
I do not think it is possible for me to prevent infections that can lead to sepsis in the survivor of sepsis or severe COVID-19 I care for.
I do not think sepsis is a problem for the survivor of sepsis or severe COVID-19 I care for.
I do not think infections that can lead to sepsis are a problem for the survivor of sepsis or severe COVID-19 I care for.
I do not think it is important to prevent infections that can lead to sepsis in the survivor of sepsis or severe COVID-19 I care for.
I do not have time to take all the steps needed to prevent infections that can lead to sepsis in the survivor of sepsis or severe COVID-19 I care for.
The health of the sepsis or severe COVID-19 survivor I care for makes it hard for me to take all the steps needed to prevent infections that can lead to sepsis.
I’m not confident the healthcare system in the area where the sepsis or severe COVID-19 survivor I care for can respond correctly to sepsis.
I’m not confident the healthcare professionals in the area where the sepsis or severe COVID-19 survivor I care for can respond correctly to sepsis.
The sepsis or severe COVID-19 survivor I care for lives very far from healthcare services.
The sepsis or severe COVID-19 survivor I care for do not have easy access to healthcare services.
I rely on telehealth services.
Other, please explain: ____________________________________________________________
I have not encountered any barriers to preventing infections that can lead to sepsis in the survivor of sepsis or severe COVID-19 I care for.
I do not try to prevent infections that can lead to sepsis in the survivor of sepsis or severe COVID-19 I care for.
Do not know/cannot recall
Prefer not to answer
In the last 2-3 months, have you looked for information about infections that can lead to sepsis for the survivor of sepsis or severe COVID-19 you care for?
Yes
No
Do not know/cannot recall
Programmer: If the respondent selects “Yes” to Q86, proceed to “SOURCES OF INFORMATION” section, else skip “SOURCES OF INFORMATION” section.
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 “Sepsis or sever COVID-19 survivors”.
Think about the visits you have had with healthcare professionals over the past 2-3 months. These include both in-person and telehealth visits. During these visits, how often did you speak with your healthcare professionals about the following?
Programmer: Include “Did not visit a healthcare professional for an illness in the past 2-3 months” as one option for all of a–f (merged cell).
|
Never |
Rarely |
Sometimes |
Often |
Always |
Do
not know/ |
Did not visit a healthcare professional in past 2-3 months |
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What are the barriers that make it hard for you to have conversations with your healthcare professional about how to prevent infections that can lead to sepsis? Select all that apply.
Programmer: Rotate response options; keep the placement of “Do not know/cannot recall,” “Prefer not to answer,” “Other,” and “I do not have any barriers to having conversations about these topics” as is.
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 problem for me.
I do not think infections that can lead to sepsis are a problem for me.
I do not have a healthcare professional 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
Programmer: If respondent selects “I do not have any barriers to having conversations about these topics,” “Do not know/cannot recall” or “Prefer not to answer,” do not allow them to select other responses.
Did you get a flu vaccine for the 2022-2023 flu season?
Yes
No
What are the barriers that make it hard for you to prevent infections that can lead to sepsis? Select all that apply.
Programmer: Rotate response options; keep the placement of “Don’t know/cannot recall,” “Prefer not to answer,” “Other,” “I do no try to prevent infections…,” and “I have not encountered any barriers to preventing infection…” as is.
I am not able to get to a doctor or nurse to discuss the steps needed to prevent infections that can lead to sepsis.
I am afraid to see a doctor or nurse because I am worried about getting COVID-19.
I am not able to access or afford supplies for cuts and wound care that I would need to prevent infections that can lead to sepsis.
I am not familiar enough with how to prevent infections that can lead to 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.
I do not think sepsis is a problem for me.
I do not think infections that can lead to sepsis are a problem for me.
I do not think it is important to prevent infections that can lead to sepsis.
I do not have time to take all the steps needed to prevent infections that can lead to sepsis.
My health makes it hard for me to take all the steps needed to prevent infections that can lead to sepsis.
I’m not confident the healthcare system in my area can respond correctly to sepsis.
I’m not confident the healthcare professionals in my area can respond correctly to sepsis.
I live very far from healthcare services.
I don’t have easy access to healthcare services.
I rely on telehealth services.
Other, please explain: ________________________________________________________
I have not encountered any barriers to preventing infections that can lead to sepsis.
I do not try to prevent infections that can lead to sepsis.
Do not know/cannot recall
Prefer not to answer
Programmer: If respondent selects “I have not encountered any barriers to preventing infections that can lead to sepsis,” “I do not try to prevent infections that lead to sepsis,” “Do not know/cannot recall” or “Prefer not to answer,” do not allow them to select other responses.
In the last 2-3 months, have you looked for information about infections that can lead to sepsis?
Yes
No
Do not know/cannot recall
Programmer: If the respondent selects “Yes” to Q91, proceed to “SOURCES OF INFORMATION” section, else skip “SOURCES OF INFORMATION” section.
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 “Parent of children ≤ 12 years old.”
Please answer the following questions about YOUR CHILD/CHILDREN WHO IS 12 YEARS OLD OR YOUNGER for whom you currently make healthcare decisions.
In the past 2-3 months, how often did you speak with your child’s healthcare professionals about the following?
|
Never |
Rarely |
Sometimes |
Often |
Always |
Do
not know/ |
Did not visit a healthcare professional in past 2-3 months |
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What are the barriers that make it hard for you to have conversations about how to prevent infections that can lead to sepsis? Select all that apply.
Programmer: Rotate response options; keep the placement of “Don’t know/cannot recall,” “Prefer not to answer,” “Other,” and “I do not have any barriers to having conversations about these topics” as is.
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 problem for my child.
I do not think infections that can lead to sepsis are a problem for my child.
My child does not have a healthcare professional 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
Programmer: If the respondent selects “I do not have any barriers to having conversations about these topics,” “Do not know/cannot recall” or “Prefer not to answer,” do not allow them to select other responses.
Did your child get a flu vaccine for the 2022-2023 flu season?
Yes
No
Do not know
What are the barriers that make it hard for you to prevent infections that can lead to sepsis in your child? Select all that apply.
Programmer: Rotate response options; keep placement of “Don’t know/cannot recall,” “Prefer not to answer,” “Other,” “I do no try to prevent infections…,” and “I have not encountered any barriers to preventing infection…” as is.
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.
I am afraid to see a doctor or nurse with my child because I am worried about getting COVID-19 or my child getting COVID-19.
I am not able to access or afford supplies for cuts and wound care that I would need to prevent infections that can lead to sepsis in my child.
I am not familiar enough with how to prevent infections that can lead to 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 in my child.
I do not think sepsis is a problem for my child.
I do not think infections that can lead to sepsis are a problem for my child.
I do not think it is important to prevent infections that can lead to sepsis in my child.
I do not have time to take all the steps needed to prevent infections that can lead to 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.
I’m not confident the healthcare system in the area where my child lives can respond correctly to sepsis.
I’m not confident the healthcare professionals in the area where my child lives can respond correctly to sepsis.
My child lives very far from healthcare services.
My child does not have easy access to healthcare services.
My child relies on telehealth services.
Other, please explain: ________________________________________________________
I have not encountered any barriers to preventing infections that can lead to sepsis in my child.
I do not try to prevent infections that can lead to sepsis in my child.
Do not know/cannot recall
Prefer not to answer
Programmer: If respondent selects “I have not encountered any barriers to preventing infections that can lead to sepsis in my child,” “I do not try to prevent infections that lead to sepsis in my child,” “Do not know/cannot recall” or “Prefer not to answer,” do not allow them to select other responses.
In the last 2-3 months, have you looked for information about infections that can lead to sepsis for your child?
Yes
No
Do not know/cannot recall
Programmer: If the respondent selects “Yes” to Q96, proceed to “SOURCES OF INFORMATION” section, else skip “SOURCES OF INFORMATION” section.
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 “Adults who care for a family member age 65+.”
Please answer the following questions about the FAMILY MEMBER AGE 65+ (family member) for whom you are currently the primary caregiver.
In the past 2-3 months, how often did you speak with your family member over 65+’s healthcare providers/help them to speak with their healthcare professionals about the following?
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Never |
Rarely |
Sometimes |
Often |
Always |
Do
not know/ |
Did not visit a healthcare professional in past 2-3 months |
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What are the barriers that make it hard for you to have conversations/help your family member age 65+ have conversations about how to prevent infections that can lead to sepsis? Select all that apply.
Programmer: Rotate response options; keep placement of “Don’t know/cannot recall,” “Prefer not to answer,” “Other,” and “I do not have any barriers to having conversations about these topics” as is.
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 infections that can lead to sepsis are a problem for my family member.
My family member does not have a healthcare professional 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
Programmer: If respondent selects “I do not have any barriers to having conversations about these topics,” “Do not know/cannot recall” or “Prefer not to answer,” do not allow them to select other responses.
Did your family member age 65+ get a flu vaccine for the 2022-2023 flu season?
Yes
No
Do not know
What are the barriers that make it hard for you to prevent infections that can lead to sepsis in your family member who is age 65+? Select all that apply.
Programmer: Rotate response options; keep placement of “Don’t know/cannot recall,” “Prefer not to answer,” “Other,” “I do no try to prevent infections…,” and “I have not encountered any barriers to preventing infection…” as is.
I am not able to get to a doctor with my family member to discuss the steps needed to prevent infections that can lead to sepsis.
I am afraid to see a doctor or nurse with my family member because I am worried about getting COVID-19 or my family member getting COVID-19.
I am not able to access or afford supplies for cuts and wound care that I would need to prevent infections that can lead to sepsis for my family member.
I am not familiar enough with how to prevent infections that can lead to sepsis in my family member.
I do not know if my family member needs to get any vaccinations.
I do not want my family member to get vaccinations.
I do not think it is possible for me to prevent infections that can lead to sepsis in my family member.
I do not think infections that can lead to sepsis are a problem for my family member.
I do not think it is important to prevent infections that can lead to sepsis in my family member.
I do not have time to take all the steps needed to prevent infections that can lead to sepsis in my family member.
My family member’s health makes it hard for me to take all the steps needed to prevent infections that can lead to sepsis.
I’m not confident the healthcare system in my area can respond correctly to sepsis.
I’m not confident the healthcare professionals in my area can respond correctly to sepsis.
I live very far from healthcare services.
I don’t have easy access to healthcare services.
I’m not confident the healthcare system in my family member’s area can respond correctly to sepsis.
I’m not confident the healthcare professionals in my family member’s area can respond correctly to sepsis.
My family member lives very far from healthcare services.
My family member does not have easy access to healthcare services.
My family member relies on telehealth services.
Other, please explain: _________________________________________________________
I have not encountered any barriers to preventing infections that can lead to sepsis in my family member.
I do not try to prevent infections that can lead to sepsis in my family member.
Do not know/cannot recall
Prefer not to answer
Programmer: If respondent selects “I have not encountered any barriers to preventing infections that can lead to sepsis in my family member,” “I do not try to prevent infections that lead to sepsis in my family member,” “Do not know/cannot recall” or “Prefer not to answer,” do not allow them to select other responses.
In the last 2-3 months, have you looked for information about infections that can lead to sepsis for your family member who is 65+?
Yes
No
Do not know/cannot recall
Programmer: If the respondent selects “Yes” to Q101, proceed to “SOURCES OF INFORMATION” section, else skip “SOURCES OF INFORMATION” section.
Programmer: Use the following section for “Healthy adults 65+ and Men 65+ with one or more chronic conditions”.
Think about the visits you have had with healthcare professionals over the past 2-3 months. These include both in-person and telehealth visits. During these visits, how often did you speak with your healthcare professionals about the following?
Programmer: Include “Did not visit a healthcare professional for an illness in the past 2-3 months” as one option for all of a–f (merged cell).
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Never |
Rarely |
Sometimes |
Often |
Always |
Did not visit a healthcare professional in past 2-3 months |
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What are the barriers that make it hard for you to have conversations with your healthcare professional about how to prevent infections that can lead to sepsis? Select all that apply.
Programmer: Rotate response options; keep placement of “Do not know/cannot recall,” “Prefer not to answer,” “Other,” and “I do not have any barriers to having conversations about these topics” as is.
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 problem for me.
I do not think infections that can lead to sepsis are a problem for me.
I do not have a healthcare professional 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
Programmer: If respondent selects “I do not have any barriers to having conversations about these topics,” “Do not know/cannot recall” or “Prefer not to answer,” do not allow them to select other responses.
Did you get a flu vaccine for the 2022-2023 flu season?
Yes
No
What are the barriers that make it hard for you to prevent infections that can lead to sepsis? Select all that apply.
Programmer: Rotate response options; keep placement of “Don’t know/cannot recall,” “Prefer not to answer,” “Other,” “I do no try to prevent infections…,” and “I have not encountered any barriers to preventing infection…” as is.
I am not able to get to a doctor or nurse to discuss the steps needed to prevent infections that can lead to sepsis.
I am afraid to see a doctor or nurse because I am worried about getting COVID-19.
I am not able to access or afford supplies for cuts and wound care that I would need to prevent infections that can lead to sepsis.
I am not familiar enough with how to prevent infections that can lead to 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.
I do not think sepsis is a problem for me.
I do not think infections that can lead to sepsis are a problem for me.
I do not think it is important to prevent infections that can lead to sepsis.
I do not have time to take all the steps needed to prevent infections that can lead to sepsis.
My health makes it hard for me to take all the steps needed to prevent infections that can lead to sepsis.
I’m not confident the healthcare system in my area can respond correctly to sepsis.
I’m not confident the healthcare professionals in my area can respond correctly to sepsis.
I live very far from healthcare services.
I don’t have easy access to healthcare services.
I rely on telehealth services.
Other, please explain: ________________________________________________________
I have not encountered any barriers to preventing infections that can lead to sepsis.
I do not try to prevent infections that can lead to sepsis.
Do not know/cannot recall
Prefer not to answer
Programmer: If respondent selects “I have not encountered any barriers to preventing infections that can lead to sepsis,” “I do not try to prevent infections that lead to sepsis,” “Do not know/cannot recall” or “Prefer not to answer,” do not allow them to select other responses.
In the last 2-3 months, have you looked for information about infections that can lead to sepsis?
Yes
No
Do not know/cannot recall
Programmer: If the respondent selects “Yes” to Q105, proceed to “SOURCES OF INFORMATION” section, else skip “SOURCES OF INFORMATION” section.
To whom or where did you go to learn about infections that can lead to sepsis? Select all that apply.
Programmer: Rotate response options; keep the placement of “Other” and “I have not tried to learn about sepsis” as is.
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 sepsis
Programmer: If a respondent selects “I have not tried to learn about sepsis” do not allow them to select other responses.
If you need to get information about sepsis, where would you prefer to get it? Select all that apply.
Programmer: Rotate response options; keep the placement of “Other” and “Do not know/unsure” 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 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: ________________________________________
Television, please specify: ______________________
Radio, please specify: __________________________
Social media (e.g., Facebook, Twitter, Instagram, LinkedIn, etc.), please specify:
Podcasts, please specify: ____________________________
Blogs, please specify: ______________________________
I do not need to get information about sepsis
Do not know/unsure
Programmer: If a respondent selects “Do not know/unsure” do not allow them to select other responses.
How trusted do you feel CDC is as a source of sepsis information?
Very trusted
Trusted
Somewhat trusted
A little trusted
Not at all trusted
Did you know that 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 Q110 proceed to Q111, else proceed to the DEMOGRAPHIC CHARACTERISTICS section.
How did you learn about CDC’s Get Ahead of Sepsis resources? Select all that apply.
Programmer: Rotate response options; keep placement of “Other” and “Do not know/cannot recall” as is.
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, LinkedIn, etc.)
Other, please specify: ______________________________
Do not know/cannot recall
Programmer: If a respondent selects “Do not know/unsure” do not allow them to select other responses.
In the past 2-3 months, did you talk with family or friends about how almost any infection can lead to sepsis?
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Yes |
No |
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Family members |
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Friends |
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In the past 2-3 months, did you talk with family or friends about signs and symptoms of sepsis?
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Yes |
No |
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Family members |
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Friends |
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In the past 2-3 months, did you talk with family or friends about who is at risk for sepsis?
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Yes |
No |
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Family members |
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Friends |
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In the past 2-3 months, did you talk with family or friends about sepsis being a medical emergency?
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Yes |
No |
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Family members |
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Friends |
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Programmer: For any response to Q116-Q117, show a screen grab of the campaign materials below. Each material and questions should be on one page.
Programmer: Fact Sheet in English:
A.
Did your healthcare professional (e.g., primary care physician, urgent care or emergency room physician, nurse practitioner, physician assistant) give you/show you this fact sheet in the last 3 months?
Yes
I did not receive this fact sheet?
Do not know/Don't recall
Did you use this fact sheet in learning about sepsis?
Yes
I did not receive this sheet
Do not know/Don't recall
Programmer: If respondent selects “I did not receive this fact sheet” or “Do not know/Don’t recall” to Q116 and Q117, skip Q118, else proceed to Q118.
How helpful for you was this fact sheet in learning about sepsis?
Very helpful
Helpful
Somewhat helpful
A little helpful
Not at all helpful
Why have you not used CDC Get Ahead of Sepsis resources to learn about sepsis? Select all that apply.
Programmer: Rotate response options; keep placement of “Other” and “Do not know” as is.
I used CDC Get Ahead of Sepsis resources, but they were not the ones shown above. If so, which ones did you use? Please specify: __________________________________
I do not usually use patient education resources to learn about any topics
I use resources developed by other organizations
I forget to use them
I do not have time to use them
I do not know where to find these resources
I looked at them, but did not find them helpful
Other, please specify: _________________________________________
Do not know
Programmer: Include one set of questions (e.g., printed media, social media) per page.
We would like to ask you a few questions about your media use and habits.
In an average month, how often do you…
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 |
Read printed magazines |
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Read printed newspapers |
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Read brochures or flyers on health-related topics |
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Read other printed media, please specify: _____________________
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In an average month, how often do you…
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 |
Use Facebook |
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Use Instagram |
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Use Twitter |
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Use LinkedIn |
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Use YouTube |
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Use other social media, please specify: ______________________
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In an average month, how often do you…
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 |
Read health websites/resources |
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Read news online |
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Read magazines online |
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Listen to internet radio |
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Watch TV/movies using streaming services (e.g., Netflix, Hulu, [Amazon] Prime Video) |
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Read blogs |
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Use search engines (e.g., Google) |
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Visit other websites, please specify: ________________
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In an average month, how often do you…
TV and Radio |
1-2 times a day |
Once a week |
1-3 times a month |
Less than once a month |
Never |
Do not know/cannot recall |
Watch television (cable, satellite, or antenna) |
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Listen to broadcast radio |
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Listen to satellite radio |
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Watch or listen to other TV or radio media, please specify: _______________________
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In an average month, how often do you…
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 |
See billboards |
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Use buses, subways, or trains |
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Use taxi cabs |
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Shop in malls |
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Shop in grocery stores |
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Shop in pharmacies (e.g., CVS, Walgreens, Walmart) |
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Visit other public places, please specify: _______________________
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In an average month, how often do you…
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 |
Visit doctor’s offices or healthcare facilities |
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Visit urgent care centers that are not in a store |
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Visit other healthcare locations, please specify: _______________________
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In an average month, how often do you…
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 |
Read emails |
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Read email newsletters about health |
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Listen to webcasts or webinars |
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Attend live events |
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Other, please specify: ______________________
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In an ideal world, where would you prefer to get information about sepsis? Select all that apply.
Programmer: Rotate response options; keep placement of “Other” and “Do not know/unsure” as is.
Family members and/or friends
My doctor/healthcare professional
Health websites/health-related mobile apps (e.g., WebMD, Mayo Clinic, etc.), please specify: ____________________________________________
Health groups/organizations (e.g., CDC, 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
Thank you. Now we would like to know more about you.
What is your ethnicity?
Hispanic or Latino
Not Hispanic or Latino
What is your race?
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
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.
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
Thank you for taking the time to participate in this important survey!
Programmer: FOR POSTTEST 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-XXXX
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Deborah W Gould |
File Modified | 0000-00-00 |
File Created | 2023-08-28 |