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Form Approved
OMB Control No.: 0920-0572
Expiration date: 08/31/2021
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 0920-0572

Informed Consent
Before beginning the survey, there are a few things you should know.
On behalf of the Centers for Disease Control and Prevention (CDC), the research firm ICF is
conducting an online survey with adults from the community to gather feedback on educational
materials related to antibiotic use. These materials were developed in partnership with the CDC, and
we hope to use what we learn from these survey results to improve these materials and/or how and
where we promote them to raise awareness within your community. We expect this survey to take
about 20 minutes. You will only be asked to complete this survey once.
We want to learn from you, so we encourage you to answer honestly. There are no right or wrong
answers. If you agree to participate in the survey, here are some points to know:
Rights Regarding Participation: Your participation in this survey is completely voluntary. You may
choose to leave the survey and/or not answer a question at any time for any reason. Refusal to
participate will involve no penalty or loss of benefits.
Privacy: We will take every precaution to protect your identity and ensure your privacy. We will keep
your name and answers to these survey questions private. Your name and contact information will be
kept separate from any survey responses. We will never use your name in any reports.
Benefits: Your participation in the survey will not result in any direct benefits to you. However, your
input will help us to develop and improve educational materials about sepsis for people like you.
Risks: There is no known risk to you for your participation in the survey.
Incentive: In appreciation of your time and participation, the recruiter will give you a token of
appreciation valued at $_______ for participating in today's survey.
Contact Information: If you have any questions about this survey or the campaign, please contact the
research director, Kristen Cincotta, PhD, at 404-320-4433.
1. Do you agree to participate in the survey?
Yes
No

Termination
Thank you for your time. Click here to exit this survey.

Screener
The results of this survey will help the Centers for Disease Control and Prevention (CDC) refine its
ongoing campaign to improve antibiotic use by helping CDC staff understand the public’s response to
the campaign and its key messages. You will be asked to complete different versions of the survey
depending on whether you have seen or heard certain messages from the CDC about antibiotic use.
2. May we ask you some questions to see if you are a good match to take this survey?
Yes
No

3. Are you a healthcare provider?
Yes
No

4. What type of healthcare provider are you?
Physician (MD or DO)

Licensed Practical Nurse (LPN)

Physician Assistant (PA)

Registered Nurse (RN)

Nurse Practitioner (NP)

None of the above

5. Do you work in an outpatient setting?
Yes
No

6. In what type of outpatient setting do you work?
Primary care practice/facility

Emergency department

Urgent care facility

None of the above

Retail health clinic

7. On average, how many hours a week do you provide patient care in an outpatient setting?
0-10 hours
11-20 hours
21-30 hours
30 or more hours

8. In what zip code do you work?

9. On average, how often do you prescribe antibiotics?
Never
1-3 times a month
Once a week
Multiple times every week

Termination: Ineligible
Thank you for your willingness to participate and answer our questions. Unfortunately, you do not
meet the criteria to continue with the survey. If you have any questionsabout your participation and/or
any questions about this survey, please contact the research director, Kristen Cincotta, Ph.D., at (404)
321-3211 orKristen.Cincotta@icf.com. Thank you for your time.

Eligible
Thank you for answering the questions. We have determined that you are a good match for this
survey. If you have any questionsabout your participation and/or any questions about this survey,
please contact the research director, Kristen Cincotta, Ph.D., at (404) 321-3211
orKristen.Cincotta@icf.com Thank you for answering the questions. We have determined that you are
a good match for this survey. If you have any questionsabout your participation and/or any questions
about this survey, please contact the research director, Kristen Cincotta, Ph.D., at (404) 321-3211
orKristen.Cincotta@icf.com.

Exposure to Campaign (All)
Now we would like to ask you about a CDC campaign on improving antibiotic use that you may or may
not have seen or heard about in the past 12 months.
10. Please indicate below whether you have seen or heard any of following campaign names or slogans in the
past 12 months.
Yes

No

A. Get Ahead of
Antibiotics
B. Flip the Script
C. Be Antibiotics Aware
D. Get Smart About
Antibiotics
E. Don't Mis-take
Antibiotics

11. In the past 12 months, did you see this logo or hear the slogan on it anywhere?

Yes
No
Don't know/cannot recall

Don't know/cannot recall

Frequency and Channel of Exposure (Exposed)
You indicated that you had seen or heard the campaign name, Be Antibiotics Aware , or seen the
campaign logo in the past 12 months.
12. In the past 12 months, approximately how often did you see CDC’s Be Antibiotics Aware campaign
messages, campaign name, or logo in PRINTED MEDIA?

1-2 times a day

Once a week

1-3 times a
month

Less than once
a month

Never

Don’t
know/cannot
recall

Poster
Fact Sheet
Brochure
Graphic
Newspaper/magazine
advertisement
Flyer
Other Printed Media
(please specify)
Other printed media (please specify)

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

1-2 times a day
Facebook
Instagram
Twitter
LinkedIn
YouTube
Other social media
(please specify)
Other social media (please specify)

Once a week

1-3 times a
month

Less than once
a month

Never

Don’t
know/cannot
recall

14. In the past 12 months, approximately how often did you see or hear CDC’s Be Antibiotics Aware campaign
messages, campaign name, or logo in ONLINE/INTERNET MEDIA?

1-2 times a day

Once a week

1-3 times a
month

Less than once
a month

Never

Don’t
know/cannot
recall

Health websites
/resources
Website advertisements
Online news articles
Streaming TV/video
services (e.g., Hulu,
Netflix, [Amazon] Prime
Video)
Blogs
Advertisements on
mobile phone (including
mobile apps)
Search engines (e.g.,
Google)
Other websites (please
specify)
Other Websites (please specify)

15. In the past 12 months, approximately how often did you see CDC’s Be Antibiotics Aware campaign
messages, campaign name, or logo in TV AND RADIO MEDIA?
1-2 times a day
Television (cable,
satellite, or antenna)
Broadcast radio
Other TV or Radio
media (please specify)
Other TV or Radio media (please specify)

Once a week

1-3 times a
month

Less than once
a month

Never

Don’t know/
cannot recall

16. In the past 12 months, approximately how often did you see CDC’s Be Antibiotics Aware campaign
messages, campaign name, or logo in PUBLIC PLACES?
1-2 times a day

Once a week

1-3 times a
month

Less than once
a month

Never

Don’t know/
cannot recall

Billboards
Bus, train, or subway
stations
On buses or taxi cabs
Advertisement in a mall
Advertisement in a
grocery store
Advertisement in a store
pharmacy (e.g., CVS,
Walgreens, Walmart)
Other public locations
(please specify)
Other public locations (please specify)

17. In the past 12 months, did you see CDC’s Be Antibiotics Aware campaign messages, campaign name, or
logo at work?
Yes, I personally placed or shared CDC’s Be Antibiotics Aware Campaign materials at my workplace in the past 12 months.
Yes, I saw CDC’s Be Antibiotics Aware Campaign at my workplace in the past 12 months, but I was not responsible for placing or
sharing it.
No, but I saw materials from another antibiotic use campaign at my workplace in the past 12 months.
No, I have not seen any materials about antibiotic use at my workplace in the past 12 months.

18. In the past 12 months, where did you see CDC’s Be Antibiotics Aware campaign messages, campaign
name, or logo at your workplace? (select all that apply)
Posters or other print material(s) designed to educate patients about appropriate antibiotic use
Posters or other print material(s) designed to improve antibiotic prescribing by healthcare providers
Video displays in patient waiting areas
Workplace website or internal email/newsletter
Email or e-newsletter from external health organization, such as a state or local public health agency or professional association
Other, please specify: ________________________

Risks and Benefits of Antibiotics: Attitudes and Beliefs (Exposed)
Next, we are going to ask you some questions to learn more about your perspective on antibiotic
prescribing. Research shows that healthcare provider face challenges to antibiotic prescribing. Your
responses on this survey will help CDC understand how to better support healthcare providers’
antibiotic prescribing. Please give us your honest responses. There are no right or wrong answers to
any of these questions.

Attitudes and Beliefs: Perceived Severity
19. Please indicate the extent to which you agree with the following statements, from strongly disagree to
strongly agree.
Strongly disagree
Antibiotic resistance is a
serious public health
issue.
Antibiotic resistance can
have serious
consequences for my
patients.
Side effects caused by
antibiotics could be very
serious for my patients.

Disagree

Neither agree nor
disagree

Agree

Strongly agree

Attitudes and Beliefs: Perceived Susceptibility
20. Please indicate the extent to which you agree with the following statements, from strongly disagree to
strongly agree.
Strongly disagree
If my patients are
prescribed antibiotics
when they’re not
needed, they could
experience minor side
effects, like a rash.
If my patients are
prescribed antibiotics,
even whether needed or
not, they could
experience very serious
health problems, such as
C. diff infection.

Disagree

Neither agree nor
disagree

Agree

Strongly agree

Attitudes and Beliefs: Perceived Benefits
21. Please indicate the extent to which you agree with the following statements, from strongly disagree to
strongly agree.
Strongly disagree
Prescribing antibiotics
only when needed is the
best care for my
patients.
Prescribing antibiotics
only when needed helps
protect my patients from
unnecessary side
effects.
Prescribing antibiotics
only when needed helps
combat antibiotic
resistance.

Disagree

Neither agree nor
disagree

Agree

Strongly agree

Behavior: Prescribing
22. In the past 12 months, please indicate how often you did the following when prescribing antibiotics.
Never
Patient satisfaction
factors into my decisions
to prescribe antibiotics.
I prescribe antibiotics
according to clinical
guidelines.
I take antibiotic
resistance into
consideration when
prescribing antibiotics to
my patients.
I consider antibiotic
adverse events, like C.
diff infection, when
prescribing antibiotics to
my patients.

Rarely

Sometimes

Often

Always

Attitudes and Beliefs: Perceived Barriers
23. What barriers do you commonly experience to prescribing antibiotics according to clinical guidelines?
(Select all that apply)
Current clinical guidance doesn’t always apply to my patients.
I am not as familiar as I would like to be with current clinical
guidance for prescribing antibiotics.

Uncertainty of diagnosis can make it challenging to determine
if the patient needs antibiotics.
I have not encountered any barriers to prescribing antibiotics
based on clinical guidelines.

My patients will be dissatisfied with their visit if I do not
prescribe antibiotics and they believe they need them for their
illness.

Don’t know/cannot recall

My patients demand antibiotics, even if I don’t think an
antibiotic is needed to treat their illness.

Other, please explain:___________

My patients are unaware of or unconcerned about potential
side effects of antibiotics, such as rash, nausea, or C. diff
infection.

Prefer not to answer

Discussing Antibiotics with Patients: Attitudes, Beliefs and Behaviors (Exposed)
24. Please indicate the extent to which you agree with the following statements, from strongly disagree to
strongly agree.
Strongly disagree
It’s important for me to
discuss with my patients
that antibiotics can
cause side effects that
can range from minor
issues, like a rash, to
very adverse events,
such as C. diff infection.
It’s important for me to
discuss with my patients
that antibiotic use can
lead to antibiotic
resistance.
It’s important for me to
help my patients
understand ways they
can feel better, such as
taking over the counter
(OTC) medications that
can help relieve
symptoms, when an
antibiotic isn’t needed to
treat their illness
It’s important for me to
educate patients about
when antibiotics are and
aren’t needed for their
illness.

Disagree

Neither Agree nor
Disagree

Agree

Strongly Agree

Discussing Antibiotics with Patients: Perceived Benefits of Conversations
25. Please indicate the extent to which you agree with the following statements, from strongly disagree to
strongly agree.
Strongly disagree
I believe that educating
my patients about
appropriate antibiotic
use can protect them
from unnecessary side
effects.
I believe that educating
my patients about
appropriate antibiotic
use can help reduce
unnecessary antibiotic
use, thus helping to
combat antibiotic
resistance.
I believe that educating
my patients about which
infections antibiotics do
and do not treat helps
them understand my
decision on whether or
not to prescribe an
antibiotic for their illness.

Disagree

Neither agree nor
disagree

Agree

Strongly agree

Behavior
26. When prescribing antibiotics, please indicate how frequently you discuss the following with your patients.
Never
When antibiotics are and
aren’t needed for their
illness.
Other ways to feel better,
such as taking OTC
medications that can
help relieve symptoms,
when a patient has an
infection that does not
need an antibiotic.
Common side effects,
such as rash, diarrhea,
and nausea, when
prescribing antibiotics.
Possible severe side
effects, such as C. diff
infection or allergic
reactions.
Antibiotic use can lead
to antibiotic resistance.

Rarely

Sometimes

Often

Always

Barriers
27. What are the barriers you commonly encounter when educating your patients on the topics of appropriate
antibiotic use, and antibiotic resistance? Select all that apply.
I am not familiar enough with these topics.
I do not feel confident educating my patients on these topics.
I do not think my patients will understand these topics.
I do not think it is important for my patients to understand these topics.
I do not think my patients will be interested in or receptive to learning about these topics.
I do not have time to educate my patients on these topics.
Other, please explain:___________
I have not encountered any barriers to educating my patients on these topics.
Don’t know/cannot recall
Prefer not to answer

28. Did you know that CDC’sBe Antibiotics Aware campaign has resources you can use tohelp educate your
patients about appropriate antibiotic use?
Yes
No

Demographic Characteristics (All)
Thank you. Now we would like to know more about you.
29. How long have you worked in your current role/position?
Less than one year

10 or more years

1-5 years

Prefer not to answer

6-9 years

30. What is your sex?
Male
Female
Prefer not to answer
Don’t know

31. How would you describe your racial background? Select all that apply.
White

American Indian or Alaska Native

Black or African American

Other, please specify: ________________

Asian

Prefer not to answer

Native Hawaiian or Other Pacific Islander

32. Are you Hispanic or Latino?
Yes
No
Prefer not to answer

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