Form Approved
OMB No.
0935-XXXX
Exp. Date XX/XX/20XX
On behalf of the MedStar-IMPAQ team, thank you for your interest and willingness to participate in this survey on the [CDS Tool Name]. Your feedback is very important to us! The information you provide is voluntary and will be kept strictly confidential and will not be reported or released in any way that allows identification of respondents. If there is a question you would rather not answer, you can skip it. Your participation in the survey will not affect your care and treatment in any way.
We are not selling anything but are conducting a survey about your experience in using [CDS Tool Name] developed under the funding of the Agency for Healthcare Research and Quality within the U.S. Department of Health and Human Services. We are interested in your experience and we hope to know how we can make the [CDS Tool Name] better for patients like you.
This survey will take 10-15 minutes to complete.
First, we would like to ask some background information.
What is your age?
18-44
45-64
65 and older
Prefer not to answer
Which best describes your gender?
Male
Female
Prefer to self-describe [Free text answer]
Prefer not to answer
Are you Hispanic or Latino/Latina?
Yes
No
Prefer not to answer
What is your race? Please select one or more.
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other, please specify [Free text answer]
Prefer not to answer
Now, we would like to ask you some questions about your decision to start using [CDS TOOL NAME].
How did you learn about [CDS TOOL NAME]?
From my care provider at MedStar Health
From another staff member at MedStar Health
In an advertisement in a MedStar Health facility
From a member of the MedStar Health research team
From another patient at MedStar Health
[Other response choices as relevant]
What was the main reason you agreed to use [CDS TOOL NAME]?
What was your biggest concern about using [CDS TOOL NAME]?
[Free text entry]
How much do you agree with the following statements?
It was easy to get started with [CDS TOOL NAME].
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
My care provider answered all my questions about [CDS TOOL NAME].
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
I am confident that [CDS TOOL NAME] protects my private health information.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
[CDS TOOL NAME] is a valuable tool for taking care of my health.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
These next questions ask about your experiences using [CDS TOOL NAME].
How often do you use [CDS TOOL NAME]?
Every day
A few times a week
Once a week
A few times a month
Once a month
Less often than once a month
Never
Once
A few times
Most times
Almost every time
How valuable is [CDS TOOL NAME] to you?
Not at all valuable
A little valuable
Very valuable
Extremely valuable
Please rank each of the parts of [CDS TOOL NAME], where 1 is the most useful and 5 is the least useful.
Your Taper Plan
Milestones
Pain Assessment
Messaging
Resources and Education
Has difficulty with [CDS TOOL NAME] ever prevented you from using it when you wanted to?
[FOR RESPONDENTS WHO CHOSE “A LITTLE/VERY/EXTREMELY DIFFICULT” FOR Q17] What part or parts of [CDS TOOL NAME] were most difficult to use?
[Free text entry]
How likely are you to keep using [CDS TOOL NAME]?
Definitely will
Probably will
Might or might not
Probably will not
Definitely will not
How can we improve [CDS TOOL NAME] to make it easier to use?
[Free text entry]
How likely are you to keep using [CDS TOOL NAME] if we made the improvement you mentioned?
Definitely will
Probably will
Might or might not
Probably will not
Definitely will not
If you plan to keep using [CDS TOOL NAME], what are your reasons for using it?
[Free text entry]
If you don’t plan to keep using [CDS TOOL NAME] or are not sure, what areas do you think need to be improved?
[Free text entry]
Please share any other thoughts you have about [CDS TOOL NAME] with us:
[Free text entry]
Thank you for completing our survey! Your answers help us improve [CDS TOOL NAME] to help other patients like you.
This survey is authorized under 42 U.S.C. 299a. The confidentiality of your responses to this survey is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. Information that could identify you will not be disclosed unless you have consented to that disclosure. Public reporting burden for this collection of information is estimated to average 15 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, 5600 Fishers Lane, Room #07W42, Rockville, MD 20857
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Elizabeth Gall |
File Modified | 0000-00-00 |
File Created | 2021-01-13 |