Pretest - screenshots

Attachment E_GAOS HCP Survey PRE-TEST HMTS.pdf

CDC and ATSDR Health Message Testing System

Pretest - screenshots

OMB: 0920-0572

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-0572 can be found here:

Document [pdf]

Download: pdf | pdf

GAOS HCP Survey COMBINED
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 healthcare professionals to gather feedback on educational
materials related to sepsis. 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 15
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.
Incentives will be provided based on the HCP audience the respondent is from. ICF will offer the
following incentive values:
·

Urgent Care NPs and PAs = $35

LTC Nurses = $35

ED Triage Nurses = $30

Family Practitioners = $25

General Medical Ward Staff = $25

1. Do you agree to participate in the survey?
Yes
No

Screener
The results of this survey will help the Centers for Disease Control and Prevention (CDC) refine and
improve its ongoing campaign to improve antibiotic use. You will be asked to complete different
versions of a survey depending on whether or not you have seen or heard certain messages from CDC
about sepsis.
2. May we ask you some questions to see if you are a good match to take this survey?
Yes
No

3. How old are you?
Prefer not to answer
How old are you?

4. In what ZIP code do you work?

5. Are you a healthcare professional (e.g., doctor, nurse, pharmacist, dietician, aid, sitter, social worker)
Yes
No

6. What type of healthcare professional are you? Please select all that apply.
Physician (MD or DO)

Certified Medical Technician (CMT)

Nurse Practitioner (NP)

Certified Nursing Assistant (CNA)

Physician Assistant (PA)

Nurse Aide or Patient Sitter

Registered Nurse (RN)

None of the above

Licensed Professional Nurse (LPN)

Prefer not to answer

Licensed Vocational Nurse (LVN)

7. In what type of setting do you work? (select all that apply)
Emergency room and/or department

Managed care medical clinic (e.g., Kaiser)

Hospital
Urgent care medical clinic

Long-term care facility (e.g., nursing home, skilled nursing
facility, long-term acute care center, adult daycare center,
dementia facility)

Private practice

None of the above

Community-based clinic or Federally Qualified Health Center

Prefer not to answer

Disqualification Page
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 questions about your participation and/or
any questions about this survey, please contact the research director, Kristen Cincotta, Ph.D., at (404)
321-3211 or Kristen.Cincotta@icf.com. Thank you for your time.

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

Exposure to Campaign
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 12 months.

Exposure to Campaign
8. Please indicate below whether you have seen or heard any of following campaign names or slogans in the
past 12 months.
Yes

Be Smart. Beat Sepsis.
Be Sepsis Aware
Health is Precious. Don’t
Get Sepsis.
Get Ahead of Sepsis
Know the Threat.
Prevent Sepsis.

9. In the past 12 months, did you see or hear this slogan and/or logo?

Yes
No
Do not recall

Do not know/cannot recall

Frequency and Channel of Exposure
You indicated that you had seen or heard the campaign name, Get Ahead of Sepsis, or seen the
campaign logo in the past 12 months.
10. In the past 12 months, approximately how often did you see CDC’s Get Ahead of Sepsis campaign
messages, campaign name, or logo in …?
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
Fact sheet
Brochure
Graphic
Newspaper/magazine
advertisement
Flyer
Other print media
(please specify)
Other print media (please specify)

11. In the past 12 months, approximately how often did you see CDC’s Get Ahead of Sepsis campaign
messages, campaign name, or logo in …?
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

Do not know/
cannot recall

12. In the past 12 months, approximately how often did you see CDC’s Get Ahead of Sepsis campaign
messages, campaign name, or logo in …?
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
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 online/internet media (please specify)

13. In the past 12 months, approximately how often did you see CDC’s Get Ahead of Sepsis campaign
messages, campaign name, or logo in …?
1-2 times a day
Television (cable,
satellite, or antenna)
Broadcast radio
Other media formats
(please specify:
_____________)
Other media formats (please specify)

Once a week

1-3 times a
month

Less than once
a month

Never

Do not know/
cannot recall

14. In the past 12 months, approximately how often did you see CDC’s Get Ahead of Sepsis campaign
messages, campaign name, or logo in …?
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
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)

15. In the past 12 months, did you see CDC’s Get Ahead of Sepsis campaign messages, campaign name, or
logo at work?
Yes, I personally placed or shared CDC’s Get Ahead of Sepsis campaign materials at my workplace in the past 12 months.
Yes, I saw CDC’s Get Ahead of Sepsis 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 sepsis campaign at my workplace in the past 12 months.
No, I have not seen any materials about sepsis at my workplace in the past 12 months.

16. In the past 12 months, where did you see CDC’s Get Ahead of Sepsis campaign messages, campaign
name, or logo at your workplace? (select all that apply)
Posters or other print material(s) designed to educate patients
about sepsis
Posters or other print material(s) designed to improve sepsis
early recognition and timely treatment by healthcare
professionals
Video displays in patient waiting areas
Other (please specify)

Workplace website or internal email/newsletter
Email or e-newsletter from external organization, such as a
state or local public health agency or professional association

Knowledge
Thinking about your knowledge and awareness of sepsis, please indicate which statements you
believe to be true.
17. About 1 in 3 patients who die in a hospital have sepsis.
TRUE
FALSE

18. More people die of heart attacks and strokes in one year than from sepsis.
TRUE
FALSE

19. Sepsis is defined as the following:
A chronic condition that mainly affects kidney function
A blood infection
The body’s extreme response to an infection
A neurological disorder resulting from the flu
Contagious illness that commonly peaks in the winter
All of the above
None of the above
Do not know

20. Almost any infection can lead to sepsis.
TRUE
FALSE

21. Which of the following types of infections, if any, are OFTEN linked with sepsis? (Select all that apply)
Ear
Skin
Lung
Eye
Urinary tract
Gut
All of the above
None of the above
Do not know

22. If your patient and/or resident is healthy, an infection isn’t anything you need to worry about.
TRUE
FALSE

23. Which of the following, if any, are the most frequently identified pathogens that cause infections that can
develop into sepsis? (Select all that apply)
Staph
pertussis
pylori
coli
botulinum
Some types of Streptococcus
All of the above
None of the above
Do not know

24. Your fast recognition and treatment of sepsis can increase your patients’ chances of survival.
TRUE
FALSE

25. Check all the signs and symptoms of sepsis below:
Excessive thirst
Clammy or sweaty skin
Confusion or disorientation
Extreme pain or discomfort
Fever, shivering, or feeling very cold
High heart rate
Shortness of breath
I do not know any of the signs and symptoms of sepsis.

26. Only doctors need to know the existing guidance for diagnosing and managing sepsis at their facility.
TRUE
FALSE

27. Which of the following activities, if any, should you do and advise your patients and/or residents to do in
order to prevent infections that can lead to sepsis? (Select all that apply)
Wash your hands regularly
Shower daily
Get recommended vaccines
Avoid public restrooms
Keep cuts and wounds clean and covered until healed
Take good care of chronic conditions
Ensure proper patient catheter removal (doctor nurse only)
All of the above
None of the above
Do not know

28. If you or your patients and/or residents suspect sepsis or have an infection that’s not getting better or is
getting worse, you should discuss with them if the infection could be leading to sepsis.
TRUE
FALSE

29. Which of the following groups of individuals are at high risk for developing infections than can lead to
sepsis, and sepsis? (Select all that apply)
Adults aged 65 and older
Children or adults with chronic conditions like diabetes, lung disease, cancer, and kidney disease
Children younger than 1 years old
Children or adults with weakened immune systems
Children or adults who have previously survived sepsis
All of the above. Anyone can get an infection.
Do not know
None of the above

30. Antibiotic therapy for patients who have developed sepsis should NOT be reassessed during the course of
treatment.
TRUE
FALSE

31. Which of the following, if any, is true about sepsis? (Select all that apply)
Only people with chronic diseases are at risk for sepsis
Sepsis can cause tissue damage, organ failure, and death
Sepsis is a medical emergency
Timely treatment can increase the chances of survival
All of the above
None of the above
Do not know

32. Which of the following is true, if any, about what you should do if you suspect sepsis? (Select all that
apply)
Alert the clinician in charge if it is not you
Start antibiotics as soon as possible, in addition to other therapies appropriate for the patient
Check patient progress frequently. Reassess antibiotic therapy in 24-48 hours to stop or adjust therapy if needed.
Identify and treat patients early
All of the above
None of the above
Do not know

Attitudes and Beliefs
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. There are no right or wrong answers to any of these
questions.
33. Please indicate the extent to which you agree with the following statements, from strongly disagree to
strongly agree.
Strongly Disagree

Disagree

Neutral

Agree

Strongly agree

My patients and/or
residents are at risk of
developing sepsis.
My patients and/or
residents are at risk of
developing infections
that could lead to sepsis.

34. Please indicate the extent to which you agree with the following statements, from strongly disagree to
strongly agree.
Strongly Disagree
If one of my patients
and/or residents
developed sepsis, it
could cause severe
problems such as tissue
damage or organ failure.
If one of my patients
and/or residents
developed sepsis, it
could lead to death.

Disagree

Neutral

Agree

Strongly agree

35. Please indicate the extent to which you agree with the following statements, from strongly disagree to
strongly agree.
Strongly Disagree
If my patients and/or
residents take proper
care of their chronic
conditions, this will
decrease their chances
of developing infections
that can lead to sepsis.
If my patients and/or
residents practice good
hand hygiene, this will
decrease their chances
of developing infections
that can lead to sepsis.
If my patients and/or
residents keep their
wounds clean and
covered, this will
decrease their chances
of developing infections
that can lead to sepsis.
If my patients and/or
residents get
recommended
vaccinations, this will
decrease their chances
of developing infections
that can lead to sepsis.
Timely treatment of
infections can increase
my patients’ and/or
residents’ chances of
survival from sepsis.
Recognizing signs and
symptoms of sepsis
early decreases my
patients’ and/or
residents’ risk of death
from sepsis.
Acting fast if I suspect
sepsis in my patients
and/or residents can
save lives.

Disagree

Neutral

Agree

Strongly agree

36. Please indicate the extent to which you agree with the following statements, from strongly disagree to
strongly agree.
Strongly Disagree
I am confident that I can
educate my patients
and/or residents on how
to prevent infections that
can lead to sepsis.
I am confident that I can
recognize the signs and
symptoms of sepsis in
my patients and/or
residents.
I am confident that I can
take rapid action to treat
sepsis when suspected
in patients.

Disagree

Neutral

Agree

Strongly agree

Behavior
We’d like to know more about conversations you might have had with your patients and/or residents
and their caregivers about sepsis.
37. Please indicate how frequently you discussed the following with your patients and/or residents and their
caregivers in the past 12 months.
Never
The importance of taking
care of chronic
conditions.
The importance of
regularly washing hands.
The importance of
keeping wounds clean
and covered until healed
The importance of
getting the
recommended
vaccinations.
The importance of
seeking immediate
medical care if an
infection is not getting
better or is getting
worse.
The importance of
knowing the signs and
symptoms of sepsis.
The importance of early
recognition and timely
treatment of sepsis.
The importance of
preventing infections
that can lead to sepsis

Rarely

Sometimes

Often

Always

N/A

38. What are the barriers you commonly encounter when educating your patients and/or residents and their
caregivers on preventing sepsis or on preventing infections that can lead to sepsis? Select all that apply.
I am not familiar enough with these topics.
I do not feel confident educating my patients/residents on these topics.
I do not think my patients/residents or their caregivers will understand these topics.
I do not think it is important for my patients/residents or their caregivers to understand these topics.
I do not think my patients/residents or their caregivers will be interested in or receptive to learning about these topics.
I do not have time to educate my patients/residents or their caregivers on these topics.
I do not think sepsis is a big problem for my patients and/or residents.
I have not encountered any barriers to educating my patients/residents or their caregivers on these topics.
I do not try to educate my patients/residents or their caregivers on preventing sepsis or on preventing infections that can lead to
sepsis
Do not know/cannot recall
Prefer not to answer
Other, please explain

39. In the past 12 months, have you suspected that a patient and/or resident at your facility had sepsis?
Yes
No

40. Please indicate how many patients and/or residents at your facility had sepsis in the past X months. (12
months [pretest]/2 months [posttest])
1
2
3
4
5 or more
Do not know

41. Please indicate how often you took the following steps for your sepsis patients in the past 12 months.
(check all that apply)
Never

Rarely

Sometimes

Often

Always

N/A

I immediately alerted
clinicians in charge
about the possibility of
sepsis in my patients
and/or residents in order
to ensure early
recognition and timely
treatment of sepsis.
I started antibiotics as
soon as possible for
sepsis patient and/or
resident, in addition to
other therapies
appropriate for the
patient and/or resident.
I checked the sepsis
patient’s and/or
resident’s progress
frequently.

42. I plan to take rapid action and initiate appropriate treatment when sepsis is suspected in my patients
and/or residents.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree

43. What are the barriers you experience to taking rapid action and initiating appropriate treatment when
sepsis is suspected in your patients and/or residents? (choose all that apply)
I am not confident I can identify the signs and symptoms of
sepsis.

It is not my role to identify sepsis and/or to alert the clinician in
charge.

I do not know how to alert the clinician in charge (it is not me).

I do not have any barriers.

I am not comfortable alerting the clinician in charge (it is not
me).

I have not had to take rapid action in my role.

Other (please specify)

44. [ALL HCPs] In the last 12 months, have you looked for information about infections that can lead to sepsis,
or sepsis?
Yes
No
Do not know/cannot recall

45. To whom or where do you go to learn about infections that can lead to sepsis, and/or sepsis? (select all
that apply)
Colleagues, other HCPs
Centers for Disease Control and Prevention (CDC) website or material. Please specify: ____________________
Peer-reviewed journals (Printed or online). Please specify: ____________________
Health websites/health-related mobile apps (WebMD, Mayo Clinic, Medscape, UpToDate, etc.). Please specify:
_____________________
Medical conferences. Please specify: __________________
Local/state health departments
Medical or professional associations. Please specify: _____________________
My place of work.
Continuing education/medical education/training courses (CE/CME, etc.). Please specify: __________________
Social media (Facebook, Instagram, Twitter, LinkedIn). Please specify: ______________________
Sepsis organizations (Sepsis Alliance, etc.). Please specify: __________________
I have not looked for information on this topic.
Other (please specify)

46. Do you have Infection Prevention and Control (IPC) practices/guidelines at your facility?
Yes
No
Don’t know

47. Do you know the content of the Infection Prevention and Control (IPC) practices/guidelines at your facility?
Yes
No

48. Do you have a sepsis protocol at your facility?
Yes
No
Don’t know

49. Do you know the content of your facility’s sepsis protocol?
Yes
No

50. Did you know that the U.S. Centers for Disease Control and Prevention (CDC) has a Get Ahead of Sepsis
webpage with resources you can use to help educate your patients about preventing infections that can lead
to sepsis, and sepsis?
Yes
No

Demographic Characteristics
Thank you. Now we would like to know more about you.
51. How long have you worked in your current role/position?
Less than one year
1-5 years
6-9 years
10 or more years
Prefer not to answer

52. What is your sex?
Male
Female
Prefer not to answer
Do not know

53. How would you describe your racial background? Select all that apply.
White
Black or African American
Asian
Native Hawaiian or Other Pacific Islander
American Indian or Alaska Native
Prefer not to answer
Other (please specify)

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

55. What is the highest degree you have received? (Please select only one)
High school Degree/GED
Associates Degree
Bachelors Degree
Masters degree
Professional degree (MD, JD, etc.)
Doctorate degree

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

File Type	application/pdf
File Modified	0000-00-00
File Created	0000-00-00