Form 0920-1154-24ES Antimicrobial Resistance Communications and Media Suppor

WS-CDC ARX – DHQP C. diff Screener

Form Approved

OMB Control No.: 0920-1154

Expiration date: 03/31/2026

Antimicrobial Resistance Communications and Media Support Services

Division of Healthcare Quality Promotion (DHQP)

Screener for C. diff Materials Testing Interviews

April 12, 2024 Final

Introduction

Hello. My name is ________ and I’m calling from _________, an independent communications firm.

You indicated that you are interested in participating in a virtual one-on-one research interview, to discuss your experiences and opinions regarding a health topic. [DO NOT DISCLOSE THE EXACT TOPIC OF DISCUSSION BEFORE THE INTERVIEW.] The discussion will last up to 1 hour. This activity is supported by the U.S. Centers for Disease Control and Prevention and interviews are being conducted by their contractual partner KRC Research.

I have a few questions to start. But first, to maintain participants’ confidentiality, we will use first names only during the interview and your name will not be used in any study materials. CDC will not receive any personally identifying information that you provide. We will be asking you a few questions to ensure we are recruiting a variety of people, but the information will not be associated with your specific name.

IF TERMINATED DURING SCREENING PROCESS: READ: “I’M SORRY, WE ALREADY HAVE ENOUGH INDIVIDUALS IN THAT CATEGORY. THANK YOU VERY MUCH FOR YOUR TIME.”

IF INDIVIDUAL EXPRESSES CONCERN DURING SCREENING: NOTE CONCERN AND REASSURE APPROPRIATELY. REMIND THAT PARTICIPATION IS VOLUNTARY, AND ANSWERS AND PARTICIPATION ARE CONFIDENTIAL.

Name: _______________________________________________________

Address (residence): _______________________________________________________

City, State, Zip: _______________________________________________________

Phone: _______________________________________________________

Email: _______________________________________________________

Recruiter: _______________________________________________________

SEPARATE CONTACT SHEET FROM THE REST OF THE SCREENER AND SHRED AT THE END OF THE PROJECT.

Recruit Summary

Eleven respondents will be recruited for this project, spread across five audiences.

Below is a summary of core qualifications. All other quotas and exclusions in the screener also apply.

Hospitalist providers	Primary care prescribers	Emergency department prescribers	Urgent care prescribers	Dentists
Recruit 3	Recruit 2	Recruit 2	Recruit 2	Recruit 2
MD or DO Specialty: internal med., family med., or infectious diseases Work involves inpatient care Setting: hospital-based (non-emergency)	MD or DO or NP or PA Specialty: internal med. or family med. Work involves outpatient primary care Setting: comm. health center, solo primary care, group primary care, multi-specialty practice	MD or DO or NP or PA Specialty: emerg. medicine Work involves emergency medicine Setting: hospital emergency department	MD or DO or NP or PA Specialty: internal med. or family med. Work involves outpatient urgent care Setting: Urgent care or walk-in clinic	DDS Specialty: general dentistry

Screening Questions

1. Are you…? MARK ALL THAT APPLY

Female		RECRUIT A MIX
Male
Transgender, non-binary, or another gender
Prefer not to answer/Decline

2. Are you a...?

Doctor of Dental Surgery (hold a DDS)		CONTINUE, SEE INSTRUCTION BELOW QUESTION
Medical Doctor (hold an MD)
Doctor of Osteopathic Medicine (hold a DO)
Physician Associate/Assistant (PA)
Nurse Practitioner (NP)
Other (Please specify)		TERMINATE

DENTISTS: MUST BE DDS

HOSPITALISTS: MUST BE MD/DO

PRIMARY CARE: 1 MUST BE MD or DO; 1 MUST BE PA or NP

EMERGENCY: 1 MUST BE MD or DO; 1 MUST BE PA or NP

URGENT CARE: 1 MUST BE MD or DO; 1 MUST BE PA or NP

3. In which state do you practice? RECORD STATE, ALSO CODE TO BELOW

Northeast: MA, ME, PA		GOAL OF NO MORE THAN 1 IN EACH REGION PER AUDIENCE
South: WV
Midwest: KS, ND
West: HI, NM, OR
Another state not listed above		TERMINATE

4. IF DENTIST (DDS) What is your dental specialty?

General Dentist		CONTINUE
Pediatric Dentist		TERMINATE
Orthodontist
Periodontist
Endodontist or Root Canal Specialist
Oral Pathologist or Oral Surgeon
Prosthodontist
Other SPECIFY

5. ALL EXCEPT DENTISTS What is your medical specialty?

Internal medicine or family medicine		PRIMARY CARE & URGENT CARE: REQUIRED HOSPITALISTS: CONTINUE
Infectious diseases		HOSPITALISTS: CONTINUE
Emergency medicine		EMERGENCY: REQUIRED
Something else		TERMINATE

6. Is direct patient care one of your primary responsibilities? (Direct contact with patients for the purpose of examination, diagnosis, treatment, and monitoring.)

Yes		CONTINUE
No		TERMINATE

7. On average, how many hours per week do you spend in direct patient care? RECORD ACTUAL HOURS

20+ hours		CONTINUE
Less than 20 hours		TERMINATE

8. Of those hours spent in direct patient care, what percentage is dedicated to adult care?

50% or more		CONTINUE
Less than 50%		TERMINATE

9. ALL EXCEPT DENTISTS Does your work primarily involve…

Outpatient primary care including health services that cover a range of prevention, wellness, and treatment for common illnesses		PRIMARY CARE: REQUIRED
Outpatient urgent care including health services that cover a range of non-life-threatening injuries and illnesses		URGENT CARE: REQUIRED
Inpatient care for hospitalized patients or emergency medicine		HOSPITALISTS & EMERGENCY: REQUIRED
Other specialty care		TERMINATE

10. ALL EXCEPT DENTISTS Which of the following best describes your practice setting?

Hospital-based setting (non-emergency)		HOSPITALIST: REQUIRED
Hospital emergency department		EMERGENCY: REQUIRED
Urgent care facility or walk-in clinic		URGENT CARE: REQUIRED
Community health center		PRIMARY CARE: REQUIRED
Solo primary care practice
Group primary care practice
Multi-specialty group practice
Other SPECIFY		TERMINATE

11. IF HOSPITAL-BASED CLINIC OR PRACTICE / HOSPITAL EMERGENCY DEPARTMENT Is the hospital where you primarily work classified as any of the following? Select all that apply. MULTISELECT

Academic medical center or teaching hospital		HOSPITALIST & EMERGENCY: MAX 1 EACH
Community hospital		HOSPITALIST & EMERGENCY: MIN 1 TOTAL
Critical access hospital		HOSPITALIST & EMERGENCY: MIN 1 TOTAL
None of these		CONTINUE

Now, a few final questions to help us ensure we have a mix of backgrounds and experiences.

12. Is the practice where you work best described as…?

Urban		RECRUIT A MIX
Suburban
Small town
Rural

13. Do you work at or are you affiliated with any of the following?

Pharmaceutical company or research lab		TERMINATE
Federal or state government agency, including a public health department
None of these		CONTINUE

14. What is your age? RECORD EXACT AGE; DO NOT READ LIST

39 or younger		CONTINUE
40-49
50-59
60 or older		MAX 3 TOTAL

15. What is your race and/or ethnicity? Select all that apply. MULTISELECT

American Indian or Alaska Native For example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc.		RECRUIT A MIX
Asian For example, Chinese, Asian Indian, Filipino, Vietnamese, Korea, Japanese, etc.
Black or African America For example, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc.
Hispanic or Latino For example, Mexican, Puerto Rican, Salvadoran, Cuban, Dominican, Guatemalan, etc.
Middle Eastern or North African For example, Lebanese, Iranian, Egyptian, Syrian, Iraqi, Israeli, etc.
Native Hawaiian or Pacific Islander For example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese, etc.
White For example, English, German, Irish, Italian, Polish, Scottish, etc.

RECRUIT MINIMUM 3 TOTAL WHO SELECT SOMETHING OTHER THAN WHITE

16. How many times within the past three months have you participated in a focus group or one-on-one interview related to your professional expertise? DO NOT READ LIST

0 or 1		CONTINUE
2 or more		TERMINATE

Invitation

Thank you for answering all my questions. As I mentioned, we respect your privacy and understand this information is confidential, and we will not disclose this information to anyone. We asked these questions because we want to speak with a wide variety of people who can provide their opinions and experiences. Based on your answers to the questions, we would like to invite you to participate in a virtual interview that will last approximately 60 minutes. During the virtual discussion, you will need to have a reliable internet connection and use a desktop or laptop computer.

You will receive $75 as a token of appreciation for your participation, which will be provided to you after you complete the discussion.

All of your feedback will be confidential and will never be reported in association with any personally identifying details like your name. To make sure we capture your remarks accurately, we will audio and video record the interview. The purpose of the recording is to make sure we report accurately, but without any personally identifying information. Is this something you are interested in and comfortable with?

Yes		CONTINUE
No		THANK AND TERMINATE

The discussion is virtual, meaning that you can participate from the comfort of your home or office. You will not need to come to a facility and can meet us from wherever you are, but you will need to be in front of a computer or tablet with internet access. The information or materials you will review will include reading and visual content, so we request that you do not participate using a cell phone. You will also have to be in a quiet place. Someone will call you before the interview to make sure all the technology needed for the interview is working properly. Is this interview something you are interested in and comfortable with?

Yes		CONTINUE
No		THANK AND TERMINATE

CONFIRM DATE AND TIME OF INTERVIEW

Please provide the best telephone number to reach you:

RECORD PHONE NUMBER

Please indicate how you would like us to confirm with you:

PHONE OR EMAIL, RECORD EMAIL IF PREFERENCE

SEPARATE THE LAST PAGE (CONTACT SHEET) AND SHRED AT THE END OF THE PROJECT

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS H21-8, Atlanta, Georgia 30333; ATTN: PRA 0920-1154