Form Approved
OMB No. 0990-0379
Exp. Date 09/30/2020
ODPHP: Page-Level Survey Question Bank
OMB Control Number: 0990-0379
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 0990-0379. The time required to complete this information collection is estimated to average 1 minute 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
Question block, option 1:
[A maximum of 3 questions from the question block below will be used at one time in order to keep response time to 1 minute or less.]
1. Did you find what you were looking for on this page?
Yes
No
2. How helpful was this page?
Very helpful
Somewhat helpful
Not helpful
3. [If Very helpful or Somewhat helpful] This information can help me:
Talk with my doctor
Get a health service (like a screening test or shot)
Make a health decision
Learn about my health
Other: ____________________________
4. What can we do to improve this page?
5. I am a… (Please select all that apply.)
<answers for HealthyPeople.gov>
Public Health
Public health professional
Community health program planner or evaluator
Epidemiologist or biostatistician
Health Care
Clinical healthcare provider (doctor, nurse, or other professional providing direct patient care)
Hospital or health system administrator
Academia
Undergraduate student
Graduate student
Undergraduate instructor
Graduate instructor
Academic researcher
Government
Federal government employee
State or local health official or employee
Other: ____________________________
<answers for healthfinder.gov>
Member of the general public
Patient
Loved one of a patient
Student
Health professional
Doctor, nurse, or another clinician
Pharmacist
Practice staff or administrator
Social worker or therapist
Health coach
Health educator
Fitness educator
Other professional
Public health professional
Librarian, researcher or educator
Marketing professional
Writer or editor of health information
Federal government staff
State government staff
Local government staff
Insurance agent
Other: ____________________________
<answers for health.gov>
Member of the general public
Medical professional (e.g., doctor or nurse)
Dietitian
Fitness or exercise specialist
Medical practice staff or hospital administrator
Public health professional
Non-governmental organization employee
Federal government employee
State or local government employee
Researcher
Educator (e.g., community health educators, teacher, professor)
Student
Other: ____________________________
6. How likely are you to use [insert tools and resources] available on this page?
1 - Not at all |
2 |
3 |
4 |
5 – A lot |
Question block, option 2:
[A maximum of 3 questions from the question block below will be used at one time in order to keep response time to 1 minute or less.]
1. Did [insert feature name] work as you expected?
Yes
No
2. Do you like the design of [insert feature name]?
Yes
No
3. [If Yes for question 1]
What part of [insert feature name] did you find most valuable?
4. [If No for question 1 or 2]
What did you dislike about [insert feature name]?
5. I am a… (Please select all that apply.)
<answers for HealthyPeople.gov>
Public Health
Public health professional
Community health program planner or evaluator
Epidemiologist or biostatistician
Health Care
Clinical healthcare provider (doctor, nurse, or other professional providing direct patient care)
Hospital or health system administrator
Academia
Undergraduate student
Graduate student
Undergraduate instructor
Graduate instructor
Academic researcher
Government
Federal government employee
State or local health official or employee
Other: ___________________________
<answers for healthfinder.gov>
Member of the general public
Patient
Loved one of a patient
Student
Health professional
Doctor, nurse, or other clinician
Pharmacist
Practice staff or administrator
Social worker or therapist
Health coach
Health educator
Fitness educator
Other professional
Public health professional
Librarian, researcher or educator
Marketing professional
Writer or editor of health information
Federal government staff
State government staff
Local government staff
Insurance agent
Other: ____________________________
<answers for health.gov>
Member of the general public
Medical professional (e.g., doctor or nurse)
Dietitian
Fitness or exercise specialist
Medical practice staff or hospital administrator
Public health professional
Non-governmental organization employee
Federal government employee
State or local government employee
Researcher
Educator (e.g., community health educator, teacher, professor)
Student
Other: ___________________________
Question block, option 3:
1. Was this page helpful?
Yes
No
2. [If Yes for question 1]
I found this page helpful because the content on the page: (Please select all that apply.)
Had the information I needed
Gave me specific ideas I can use
Was easy to understand
Was trustworthy
Was up to date
Was well written
Other: ____________________________
3. [If No for question 1]
I didn’t find this page helpful because the content on the page: (Please select all that apply.)
Had too little information
Had too much information
Was confusing
Was out of date
Was poorly written
Wasn’t what I was looking for
Wasn’t what I expected
Other: ____________________________
Question block, option 4:
1. Did you find what you were looking for?
Yes
Partially
No
2. [If Partially or No for question 1]
I didn’t find everything I was looking for because: (Please select all that apply.)
There were too many links
There wasn’t enough information
Links were hard to understand
Text or graphics were hard to read or see
There were technical issues
This page wasn’t what I was looking for
Other: ____________________________
3. What can we do to make this page better?
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Jennifer Barone |
File Modified | 0000-00-00 |
File Created | 2021-01-21 |