Form 1 Survey

APPENDIX A

SURVEY INSTRUMENT

OMB No 0925-0520

Exp. Date 09/30/2012

NCCAM Clearinghouse Telephone Survey

Public reporting burden for this collection of information is estimated to average 4.5 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0530). Do not return the completed form to this address.

May I ask you a few questions to help us evaluate our program and see whom we are serving?

This NCCAM-sponsored survey should take approximately 4 to 5 minutes. Your response will be completely confidential. Participation is voluntary; you may decline to answer any or all of the questions.

Have you taken the survey before?

Do you want to take the survey based on today’s call?

NOTE: Responses in all capital letters are NOT read aloud to the respondent.

1. Have you contacted us before?

YES
NO
DON'T KNOW/DON'T REMEMBER
DID NOT REPLY

2. How did you first find the NCCAM Clearinghouse telephone number?

NCCAM WEBSITE
FROM ANOTHER WEBSITE
WRITTEN CORRESPONDENCE FROM NCCAM CLEARINGHOUSE
REFERRED BY FRIEND/FAMILY
REFERRED BY HEALTH CARE PROVIDER
REFERRED BY CO-WORKER OR COLLEAGUE
MEDIA(MAGAZINE, NEWSPAPER, TELEVISION, RADIO)
DON'T KNOW/DON'T REMEMBER
OTHER (SPECIFY)
DID NOT REPLY

3. Please tell me if you strongly agree, agree, disagree, or strongly disagree with the following statements about the NCCAM Clearinghouse:

STRONGLY AGREE

AGREE
DISAGREE
STRONGLY DISAGREE
DID NOT REPLY

The information provided to me was appropriate to the question I asked.



The way information was communicated was clear and easy to understand.



Overall, I was satisfied with the information I received today.

4. Which of the following best describes you? (Select one.)

Patient
Family or friend of patient
Interested public
CAM practitioner
Other health care provider
Researcher or grant applicant
Journalist/media professional
Student
Other (specify) 
DID NOT REPLY

5. What is your age?

20 or under
21-30
31-40
41-50
51-60
61-70
71 or over

DID NOT REPLY

6. What is your gender?

Female
Male
DID NOT REPLY

7. What is the highest level of education you have completed?
[Only ask patients/spouse, relative, friend/general public]

  

High school graduate

Some college

College graduate

Post-graduate

DID NOT ASK
DID NOT REPLY

8. Race and Ethnicity (Click here for definitions.)
 

Ethnicity:
 

Hispanic or Latino
Not Hispanic or Latino
I DO NOT WISH TO PROVIDE THIS INFORMATION

Race: (Select all that apply.)

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
I DO NOT WISH TO PROVIDE THIS INFORMATION

9. What country are you calling from?

UNITED STATES
ASK FOR HOME ZIP CODE (United States only)

SPECIFY COUNTRY

That concludes our survey. Thank you for participating. Please call us again if you have other questions. Thank you for calling the NCCAM Clearinghouse.