Form #3 Form #3 NH Provider Pre-Implementation Questionnaire

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

Nursing Home Provider Pre-Intervention Questionnaire

1. What is your title?

2. List your clinical training (residency and fellowship).

3. How long have you been in practice?

4. How long have you been providing care for resident(s) in this facility?

5. What percent of your week is spent caring for residents of nursing homes?

6. In your opinion, how well do you feel that you know the antibiotic sensitivity/resistance pattern of common infections in this facility?

   • Response coded on 5-point Likert scale with”1” indicating very well to “5” indicating very poorly.

7. Are you familiar with antibiograms? Yes/No

8. Have you used antibiograms in the nursing home setting? Yes/No

   • In your opinion, on a scale of 1 to 5 with ‘1’ indicating very minimal usefulness and ‘5’ very useful, how useful are antibiograms in the nursing home setting for selecting the most effective antibiotic for a particular infection or organism? __________. Please explain.

   • In your opinion, on a scale of 1 to 5 with ‘1’ indicating very minimal usefulness and ‘5’ very useful, how useful are antibiograms, in general, for selecting the most effective antibiotic for a particular infection or organism? ___________. Please explain.

9. Have you used antibiograms at another health care setting? Yes/No

   • What setting?

     1. Hospital

     2. Home Health

     3. Clinic

     4. Other _______________

   • In your opinion, on a scale of 1 to 5 with ‘1’ indicating very minimal usefulness and ‘5’ very useful, how useful are antibiograms in the setting noted above for selecting the most effective antibiotic for a particular infection or organism? __________. Please explain.

10. If you are currently using antibiograms or have used them in the past, please answer the following:

    • How is the information communicated to you?

      1. Fax

      2. Email

      3. Mail

      4. Other _____________

    • Is this method of communication convenient and efficient? Yes/No

    • How could communication of antibiograms be improved?

__________________________________

11. If not using antibiograms, please complete the following statement:

    • I would use antibiograms if ____________________________________________________________

Public reporting burden for this collection of information is estimated to average 10 minutes per response, the estimated time required to complete the survey. 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: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

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