Pre Discussion Information Sheet
Consumer Sepsis Focus Groups
Please provide some information about yourself by completing this questionnaire. We will not report any of your responses by name. Thank you.
What is your age? ___________
Would you describe yourself as Hispanic or Latino?
Yes
No, not Hispanic or Latino
How would you describe your racial background? Check all that apply
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
What is your highest education level completed? (Check only one)
11th grade or less
12th grade without a high school diploma
12th grade with a high school diploma
GED
Some college or technical school (1–3 years)
Associate degree
Completed college (4-year degree)
Graduate or professional degree (Master’s degree or higher)
Refused/unknown
What is your current employment status? (Check only one)
Full-time employment for wages
Part-time employment for wages
Self-employed for wages
Presently not employed outside the home, looking for work
Presently not employed outside the home, not looking for work
Unable to work
Refused/unknown
What do you do for a living? What is your occupation/profession? ______________________
What is your total household income from all sources?
$0–$24,999
$25,000–$49,999
$50,000–$74,999
$75,000–$99,999
$100,000 or more
Refused/unknown
How many children under the age of 18 are currently living with you in your home? ______
Do you have a relative more than 65 years of age living with you in your home?
No
Yes
Refused/unknown
9a. If yes, are you considered that person’s primary caregiver? A primary caregiver is the person who takes primary responsibility for someone who cannot carefully for themselves. For example, this can mean doing someone’s cooking for them, or making sure they take their medication.
Yes
No
Refused/unknown
Are you a caretaker of another person (e.g., parent, older relative) who does not live in your home?
No
Yes
Refused/unknown
Where do you go most often for health care when you are sick? (Check all that apply)
Doctor's office or HMO (health maintenance organization)
A health department
A clinic or health center (e.g., community health center)
A senior recreation or community center
A store (e.g., supermarket, drug store)
Hospital
Emergency room
Workplace
School
Some other place (Specify): _____________________
I don’t know
Refused/unknown
Which type of health care professional do you speak to about your health most often? (Check all that apply)
Doctor
Physician Assistant
Nurse
Pharmacist
Community health worker (e.g., village health worker, community health aide, community health promoter, lay health advisor)
Other (Specify): __________________
Refused/unknown
Please indicate below from which of the following sources you normally get your health information about infections: (Check all that apply)
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Please indicate below from which of the following sources do you usually get information about preventing infections: (Check all that apply)
Television
Radio
Newspapers
Magazines
Internet
Mobile Apps
Doctor visits
Church or religious organizations
Friends
Family
Other
Refused/Unknown
Don’t Look for information on this topic
Please indicate below from which of the following sources do you usually get information about managing chronic conditions: (Check all that apply)
Television
Radio
Newspapers
Magazines
Internet
Mobile Apps
Doctor visits
Church or religious organizations
Friends
Family
Other
Refused/Unknown
Don’t Look for information on this topic
Please indicate below from which of the following sources do you usually get information about sepsis: (Check all that apply)
Television
Radio
Newspapers
Magazines
Internet
Mobile Apps
Doctor visits
Church or religious organizations
Friends
Family
Other
Refused/Unknown
Don’t Look for information on this topic
Thank you for completing this questionnaire.
| File Type | application/msword |
| File Modified | 2017-01-27 |
| File Created | 2017-01-25 |