Attachment B. Feedback Questionnaire
Form Approved
OMB No. 0920-1154
Expiration Date 01/31/2020
Hospital Antibiotic Stewardship Core Element Assessment
Feedback Questionnaire
Thank you for taking the time to complete the Hospital Antibiotic Stewardship Core Element Assessment. Below is a series of questions to help us identify aspects of the assessment that may need revision due to unclear language or formatting, as well as to help us understand which components of the seven core elements are most important and relevant to the type of facility you work in (academic acute care, non-academic acute care, or critical access hospital). Your honest and detailed responses will help CDC to make any necessary edits and improvements to this assessment.
The questions are organized into the same sections as the assessment that you just completed. Please feel free to refer back to the assessment as needed to answer the questions below.
Instructions
Are the assessment instructions clear? ☐Yes ☐No
If No, please describe needed clarification(s).
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Please describe additional information that would be useful to include in the instructions, if any.
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Leadership Support
Are there any items in the Leadership Support section that are unclear? ☐Yes ☐No
If Yes, please specify (by item number) necessary clarification(s).
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Is it feasible for you to obtain information on all items in the Leadership Support section?
☐Yes ☐No
If No, please specify which items (by item number) are difficult to assess and why.
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Please identify any items in the Leadership Support section that you feel are not relevant to the hospital setting in which you work (academic acute care, non-academic acute care, or critical access). For items that are not relevant to your hospital setting, please explain why. If they are all relevant, please indicate such.
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Please identify up to 3 items in the Leadership Support section that you feel are most critical to the success of an antibiotic stewardship program the hospital setting in which you work, and why.
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Are there any critical aspects of Leadership Support that are missing from the assessment?
☐Yes ☐No
If Yes, please describe.
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Accountability and Drug Expertise
Are there any items in the Accountability and Drug Expertise section that are unclear? ☐Yes ☐No
If Yes, please specify (by item number) necessary clarification(s).
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Is it feasible for you to obtain information on all items in the Accountability and Drug Expertise section?
☐Yes ☐No
If No, please specify which items (by item number) are difficult to assess and why.
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Please identify any items in the Accountability and Drug Expertise section that you feel are not relevant to the hospital setting in which you work (academic acute care, non-academic acute care, or critical access). For items that are not relevant to your hospital setting, please explain why. If they are all relevant, please indicate such.
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Please identify up to 3 items (or sub-items) in the Accountability and Drug Expertise section that you feel are most critical to the success of an antibiotic stewardship program in your hospital setting and why.
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Are there any critical aspects of Accountability and Drug Expertise that are missing from the assessment?
☐Yes ☐No
If Yes, please describe.
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Actions to Support Optimal Antibiotic Use
Are there any items in the Actions section that are unclear? ☐Yes ☐No
If Yes, please specify (by item number) necessary clarification(s).
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Is it feasible for you to obtain information on all items in the Actions section?
☐Yes ☐No
If No, please specify which items (by item number) are difficult to assess and why.
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Please identify any items in the Actions section that you feel are not relevant to the hospital setting in which you work (academic acute care, non-academic acute care, or critical access). For items that are not relevant to your hospital setting, please explain why. If they are all relevant, please indicate such.
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Please identify up to 3 items in the Actions section that you feel are most critical to the success of an antibiotic stewardship program in your hospital setting and why.
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Are there any critical Actions to Support Optimal Antibiotic Use that are missing from the assessment?
☐Yes ☐No
If Yes, please describe.
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Tracking and Monitoring Antibiotic Prescribing, Use, and Resistance
Are there any items in the Tracking and Monitoring section that are unclear? ☐Yes ☐No
If Yes, please specify (by item number) necessary clarification(s).
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Is it feasible for you to obtain information on all items in the Tracking and Monitoring section?
☐Yes ☐No
If No, please specify which items (by item number) are difficult to assess and why.
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Please identify any items in the Tracking and Monitoring section that you feel are not relevant to the hospital setting in which you work (academic acute care, non-academic acute care, or critical access). For items that are not relevant to your hospital setting, please explain why. If they are all relevant, please indicate such.
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Please identify up to 3 items in the Tracking and Monitoring section that you feel are most critical to the success of an antibiotic stewardship program in your hospital setting and why.
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Are there any critical aspects of Tracking and Monitoring Antibiotic Prescribing, Use and Resistance that are missing from the assessment?
☐Yes ☐No
If Yes, please describe.
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Reporting Information on Improving Antibiotic Use and Resistance
Are there any items in the Reporting Information section that are unclear? ☐Yes ☐No
If Yes, please specify (by item number) necessary clarification(s).
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Is it feasible for you to obtain information on all items in the Reporting Information section?
☐Yes ☐No
If No, please specify which items (by item number) are difficult to assess and why.
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Please identify any items in the Reporting Information section that you feel are not relevant to the hospital setting in which you work (academic acute care, non-academic acute care, or critical access). For items that are not relevant to your hospital setting, please explain why. If they are all relevant, please indicate such.
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Please identify the item in the Reporting Information section that you feel is most critical to the success of an antibiotic stewardship program in your hospital setting and why.
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Are there any critical aspects of Reporting Information on Improving Antibiotic Use and Resistance that are missing from the assessment?
☐Yes ☐No
If Yes, please describe.
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Education
Are there any items in the Education section that are unclear? ☐Yes ☐No
If Yes, please specify (by item number) necessary clarification(s).
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Is it feasible for you to obtain information on all items in the Education section?
☐Yes ☐No
If No, please specify which items (by item number) are difficult to assess and why.
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Please identify any items in the Education section that you feel are not relevant to the hospital setting in which you work (academic acute care, non-academic acute care, or critical access). For items that are not relevant to your hospital setting, please explain why. If they are all relevant, please indicate such.
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Please identify the top 2 items in Education section that you feel are most critical to the success of an antibiotic stewardship program in your hospital setting and why.
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Are there any critical aspects of Education that are missing from the assessment?
☐Yes ☐No
If Yes, please describe.
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Additional Feedback
Please share any additional feedback about the assessment that is not included above (optional).
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Would it be OK for someone from CDC to contact you if we have any questions about your feedback?
☐Yes ☐No
If Yes, please share the best means to reach you (phone number, email address):
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Public reporting burden of this collection of information is estimated to average 60 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 0920-1154
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Paek, Margaret (CDC/OPHSS/CSELS) (CTR) |
| File Modified | 0000-00-00 |
| File Created | 2021-01-22 |