Form #6 Form #6 Patient Healthcare Use Questionnaire

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Health care Use Questionnaire

You are being asked to voluntarily participate in a study. The purpose of this study is to understand health care use patterns and MRSA infections. The intended result of this study is to understand the risk factors for developing MRSA infections.

Individuals who have received some health care (i.e., doctor visit, dialysis, outpatient surgery) in the last 12 months can voluntarily participate in the study by completing this survey.

If you choose to participate in the study, please fill out the survey packet; it will take about

15 minutes. Please answer the questions by marking the response that best answers the question.

Minimal risks are involved. If you do not feel comfortable answering a certain question, then you do not need to answer the question. You may choose to withdraw from the study at any time.

Confidentiality of your answers will be maintained.

Public reporting burden for this collection of information is estimated to average XX minutes per response, the estimated time required to complete the survey. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

Instructions

• The survey takes about 15 minutes to complete

• You can use either a pen or a pencil to mark your responses

• Your responses will remain strictly confidential and will not be shared with anyone outside the IUPUI research team. Only the aggregate findings will be shared

• Questions appear on both sides of each sheet

• Please answer each question honestly. Although some questions may appear similar, every question has been selected carefully. There are no ‘trick’ questions or right or wrong answers

Please check the answer that best applies.	No	Yes
In the last year, did anyone in your household have a MRSA infection?	□	□
In the last year, did you share personal items (e.g. uniforms, clothes, razors, washcloths) that were used by a person infected with MRSA or a person with a history of MRSA infection?	□	□
In the last year, did you have dialysis?	□	□	If yes, please give Dates: Modality:
In the last year, did you have any outpatient surgical procedures?	□	□	If yes, please give Dates:
In the last year, did you use IV medications at home?	□	□	If yes, please give Dates: Types:
In the last year, did you have an IV catheter while at home?	□	□
In the past year, were you admitted to any of the following facilities:
Acute Care Hospital	□	□	If yes, please give Dates:
Long Term Care Facility	□	□	If yes, please give Dates:
Nursing Home	□	□	If yes, please give Dates:
Skilled Nursing Facility	□	□	If yes, please give Dates:
Hospice	□	□	If yes, please give Dates:
In the past year, did you seek care at the Emergency Room?	□	□	If yes, please give Dates:

Please check the answer that best applies.	No	Yes
In the past year, did you take any antibiotics?	□	□	If yes, please give Dates: Types:
In the past year, did you have any outpatient procedures done? These include endoscopy, colonoscopy, or interventional radiology procedure.	□	□	If yes, please give Dates:
Have you ever had a MRSA infection?	□	□

Please check or fill in the answer.
In the past year, how many outpatient medical visits did you have?	□ zero □ 1-2 □ 3-4 □ 5-8 □ 9-12 □ more than 13
In what year were you born?	|__|__|__|__| YYYY
What is your gender?	□ Male □ Female
Are you Spanish/Hispanic/Latino?	□ No □ Yes, Mexican, Mexican Am., Chicano □ Yes, Puerto Rican □ Yes, Cuban □ Yes, other Spanish/Hispanic/Latino
What is your race? (MARK ONE OR MORE RACES)	□ Asian □ American Indian or Alaska Native □ Black or African American □ Native Hawaiian or Other Pacific Islander □ White
What is your zip code?	|__|__|__|__|__|
How many people live in your household (including yourself)?	|__|__|