0920-0953 Pre-test Demographic Data Survey For Occupational Data F

Attachment A

Pretest

Form Approved

OMB No. 0920-0953

Exp. Date 08/31/2021

PRE-TEST DEMOGRAPHIC DATA SURVEY FOR occupational Data for Health (ODH) Prototype usability Testing

Please circle or highlight your answers.

1. What is your current employment status?

   • Employed

   • Unemployed, not seeking employment

   • Unemployed, seeking employment

   • Prefer not to say

2. What is your current retirement status?

   • Not retired

   • Retired

   • Prefer not to say

3. What is your age bracket?

   • 18-25

   • 26-39

   • 40-59

   • >60

   • Prefer not to say

4. What is your gender identify?

Female

Male

Non-binary/third gender

Prefer to self-describe________________________________________

Prefer not to say

Public reporting burden of this collection of information is estimated to average 7 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0953).

5. What is the highest level of education you’ve achieved?

High-school diploma or GED

Some college

College degree

Graduate degree

None of the above

Prefer not to say

6. Please rate your comfort level using computing devices:

Low

Moderate

High

Prefer not to say

7. Please tell us about your computing device usage:

Often throughout the day

A few times a day

Several times a week

Rarely

Never

Prefer not to say

8. Do you have any prior or current professional experience with electronic health records software (EHRs)?

Yes

No

Prefer not to say

9. Do you have any prior or current experience working in a health-related field?

Yes

No

Prefer not to say

10. Have you ever held a job or worked at a business?

Yes

No

Prefer not to say

If you answered yes to the previous question, please answer the following two questions.

11. What kind of business or industry was this? (For example: TV and radio mgt., retail shoe store, State Department of Labor)

__________________________________________________________________________________________

12. What kind of work were you doing? (For example: farming, mail clerk, computer specialist.)

_________________________________________________________________________________________