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OMB No. 0990‐0321
Exp. Date XX/XX/20XX
Attachment 3: Proposed Survey Questions
PageLevel Questions
Was this page helpful?
Yes
No
IF YES: Which of the following do you feel is the real strengths of this webpage? [Please select one]
Useful information
Trustworthy information
Up to date information
Easy to find information
Well‐written content
Other , please specify ___________________
None of the above
IF NO: Which of the following do you feel is a weakness of this webpage? [Please select one]
Confusing information
Too much information
Too little information
Out of date information
Hard to find information
Poorly written content
Other , please specify ___________________
None of the above
How can we make this webpage better? [COMMENT BOX]
SiteLevel Questions
Based on today’s visit, how would you rate your site experience overall?
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According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0990‐0321. The time required to complete this
information collection is estimated to average 12 minutes per response, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200
Independence Ave., S.W., Suite 336‐E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
[Type text]
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Which of the following best describes the primary purpose of your visit?1
Browse the site.
Check the HHS Reporting Readiness Tool.
Complete time and attendance sheet.
Find a form.
Find a hospital, nursing home or other medical facility.
Find a report.
Find data sets.
Find dental providers in my state.
Find health insurance for myself or a family member.
Find information about government initiatives on preventing Medicare fraud.
Find information on Health Insurance Portability and Accountability Act (HIPAA).
Find information on how I can prevent and protect myself from Medicare fraud.
Find insurance providers in my state.
Find out about events (conferences, etc.).
Find out about FedStrive activities.
Find out about Sustainability/GoGreen initiatives.
Find out how the new law affects me (and my family).
Find out how to prepare, cook, or store food safely.
Find out how to report fraud.
Find out where I can get a flu shot.
Find regulations and guidance for health practitioners.
Find the symptoms of flu.
Get basic information about flu.
Get contact information.
Get details about a food recall or alert.
Get healthcare cost information.
Get information about a specific type of food.
Get information about a specific type of illness or food poisoning.
Get information about health issues.
Get information about HHS grants.
Get information about HHS jobs.
Get information about standards and policies.
Get information about the flu vaccination.
Get information about usability testing.
Get information about usability.
Get involved in discussions on health technology matters.
Help enroll kids in CHIP and Medicaid.
Learn about the Affordable Care Act.
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This is a comprehensive list of potential responses for this question. Actual surveys will only display no more than
10 options from this list.
[Type text]
Learn about CHIP.
Learn about Medicaid.
Learn about Medicare fraud.
Learn about my rights as a health insurance consumer.
Learn about opportunities in the health community.
Learn about prevention and wellness.
Learn about the American Recovery & Reinvestment Act (ARRA).
Learn about the Department of Health and Human Services.
Learn more about the program(s).
Read the blog.
Read the most recent news.
Read the recovery plans.
Read/download publications.
Read/find an announcement.
Report a problem with food or food poisoning.
Sign up for e‐mail updates.
Take training courses.
Other. Please specify _____________________.
None of the above.
Were you able to complete the purpose of your visit today?
Yes
No
IF YES: What do you value most about the website? [COMMENT BOX]
IF NO: Please tell us why you were not able to fully complete the purpose of your visit today.
[COMMENT BOX]
How do you prefer to find things (navigate) on the site? [Please select one]
• A to Z Index
• External Search Engine (eg. Google, Yahoo)
• Navigation Tabs (top or left‐side of page)
• Scan the page
• Site Search Box (top of the page)
• Other. Please specify _____________________.
• None of the above.
Demographic Questions
Which of the following word or phrase best describes you?
Health Professional
Human Services Professional
Beneficiary
Business Owner
Lawyer
Consultant
[Type text]
Non‐profit organization
HHS Employee
Other Federal Government Employee
State/Tribal/Local Government Employee
Teacher
Student
Journalist
Librarian
Member of the General Public
Other , please specify ___________________
Please select the statement that best applies to you.
I am:
Female
Male
I am:
Less than 18 years old
18‐24 years old
25‐34 years old
35‐49 years old
50‐64 years old
65 years old or older
My first language is:
English
Spanish
Chinese
Other
Please indicate the highest level of school you have completed thus far.
I am still in elementary or middle school
I am still in high school
I did not receive a high school diploma or equivalent degree
I attended a professional or vocational school
I attended, but did not graduate from college
I am a college graduate
I have obtained some post graduate education or training
I have a professional or graduate degree
Please complete the following sentences:
I am usually on the Internet, at work, home or school, not including email _ days a week.
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[Type text]
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I am usually on the Internet, at work, home or school, not including email _ hours a day.
Less than one
1‐2 hours
3‐4 hours
5‐6 hours
7‐8 hours
9‐10 hours
11‐12 hours
More than 12 hours
File Type | application/pdf |
File Title | Microsoft Word - surveys-questions-v6.docx |
Author | achaia.walton |
File Modified | 2011-04-22 |
File Created | 2011-04-22 |