6 Custom Web Survey with Consumer and Provider Paths

Federal COVID Response - Audience Feedback to Inform Ongoing Messaging and Strategies for "Combat COVID" (OD)

Attachment 6 - Custom Web Survey with Consumer and Provider Paths 061721

OMB: 0925-0769

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0925-0769 can be found here:

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Welcome Screen - ALL RESPONDENTS

dmConsent – ALL RESPONDENTS

Public reporting burden for this collection of information is estimated to average 15 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 current

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 (XXXX-XXXX). Do

not return the completed form to this address.

[IF dmConsent/1 PROCEED TO dmCntry.]

[IF dmConsent/2 NO TERMINATE IMMEDIATELY.]

dmCntry – ALL RESPONDENTS

Shape3

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[IF dmCntry/244 UNITED STATES OF AMERICA PROCEED TO dmGen & dmAge.]

[IF hCntry DOES NOT EQUAL dmCntry TERMINATE IMMEDIATELY.]

dmGen & dmSex & dmAge – ALL RESPONDENTS

Shape4

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[IF dmAge/18+ PROCEED TO dmHispUS.]

[IF NOT 18+ TERMINATE IMMEDIATELY.]

dmHispUS – ALL US RESPONDENTS

Shape5

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[PROCEED TO dmRaceMUS.]

dmRaceMUS – ALL US RESPONDENTS

Shape6

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[PROCEED TO Q5.]

Q5 – ALL US RESPONDENTS

Shape7

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[IF Q5/1-20, PROCEED TO dmEmploy.]

[MUST RESIDE IN TARGET DMA 1-20. TERMINATE IF Q5/96 – None of the above.]

dmEmploy – ALL US RESPONDENTS

Shape8

OMB Control Number: XXXX-XXXX Expiration Date: XX/XX/XXXX

[IF dmEmploy/1,2,3,4 PROCEED TO Q10.]

[IF dmEmploy/5-10 PROCEED TO Q100]

Q10 - EMPLOYED (netEmploy/1)

Shape9

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[IF Q10/12 HEALTHCARE PROCEED TO Q20.]

[IF Q10/1-11,13-20 PROCEED TO Q100.]

Q20 - EMPLOYED IN HEALTHCARE (Q10/12) AND HCP SAMPLE SOURCE (Q1/2)

Shape10

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[IF HCP SAMPLE SOURCE Q1/2, MUST SELECT 1, 2, 4, 5, 6, 8, 9, 10 TO QUALIFY. PROCEED TO Q3. TERMINATE OTHERS]

Q30 - HCP SAMPLE (Q1/2) AND WORK IN QUALIFYING SETTING (Q20/1,2,4,5,6 OR 8)

Shape11

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[IF HCP SAMPLE SOURCE (Q1/2) MUST SELECT 2/CLINICAL TO QUALIFY. PROCEED TO Q40. TERMINATE OTHERS]

Q40 - HCP SAMPLE (Q1/2) AND CLINICAL HEALTHCARE WORKER (Q30/2)

Shape12

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[IF HCP SAMPLE SOURCE (Q1/2) MUST SELECT 1, 2, 3, 6, 7, 8 OR 9 TO QUALIFY. PROCEED TO Q50. TERMINATE OTHERS]

Q50 - HCP SAMPLE (Q1/2) AND TARGET ROLE (Q40/3,6-7)

Shape13

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[IF HCP SAMPLE SOURCE (Q1/2) MUST SELECT 2/YES TO QUALIFY. PROCEED TO Q60 TERMINATE OTHERS]

Q60 - HCP SAMPLE (Q1/2) AND TREAT COVID PATIENTS (Q50/2)

Shape14

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

QUALIFICATIONS

Consumers (Q1/1)

Live in target DMA (Q5/1-20)
Representative sample 18+

Healthcare Providers (Q1/2)

Live in target DMA (Q100/1-20)
Qualifying Setting (Q20/1, 2, 4, 5, 6, 8, 9, 10)
In Clinical Role (Q30/2)
Qualifying Specific Role (Q40/1,2,3,6,7,8,9)

Treat patients with COVID-19 (Q50/2)

Q100 – QUALIFIED CONSUMER RESPONDENTS

Shape15

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[IF QUALIFIED HCP (Q99/2) AND FAMILIAR (Q100 RATING 3-5) WITH TREATMENT TRIALS (Q100 CARD/2) PROCEED TO Q105.]

[IF QUALIFIED CONSUMER (Q99/1) AND FAMILIAR (Q100 RATING 3-5) WITH TREATMENT TRIALS (Q100 CARD/2) PROCEED TO Q108.]

Q105 - QUALIFIED HCP (Q99/2) AND FAMILIAR (Q100 RATING 3-5) WITH TREATMENT TRIALS (Q100 CARD/2)

Shape16

OMB Control Number: XXXX-XXXX Expiration Date: XX/XX/XXXX

[ALL QUALIFIED HCP PROCEED TO Q108.]

Q108 - AWARE OF CLINICAL TRIALS (Q100/2-5)

Shape17

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[ALL PROCEED TO Q110.]

Q110 - QUALIFIED RESPONDENTS

Shape18

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[ALL PROCEED TO Q111.]

Q111 - QUALIFIED RESPONDENTS

Shape19

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[ALL PROCEED TO Q115.]

Q115 - QUALIFIED RESPONDENTS

Shape20

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[ALL PROCEED TO Q119.]

Q119 - QUALIFIED RESPONDENTS

Shape21

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[ALL PROCEED TO Q120.]

Q120 - QUALIFIED RESPONDENTS

Shape22

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[ALL PROCEED TO Q125.]

Q125 - QUALIFIED RESPONDENTS

Shape23

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[QUALIFIED CONSUMERS (Q99/1) PROCEED TO Q200.]

[QUALIFIED HCPS (Q99/2) PROCEED TO Q130.]

Q130 - QUALIFIED HCP (Q99/2)

Shape24

OMB Control Number: XXXX-XXXX Expiration Date: XX/XX/XXXX

[QUALIFIED HCPS (Q99/2) PROCEED TO Q135.]

Q135

Shape25

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[QUALIFIED HCPS (Q99/2) AND Q135/1-2 PROCEED TO Q136.]

[QUALIFIED HCPS (Q99/2) AND Q135/3-5 PROCEED TO Q137.]

Q136 - QUALIFIED HCP (Q99/2) AND Q135/1-2

Shape26

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[ALL PROCEED TO Q200.]

Q137 - QUALIFIED HCP (Q99/2) AND Q135/4-5

Shape27

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[ALL PROCEED TO Q200.]

Q200 - ALL RESPONDENTS

Shape28

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[ALL PROCEED TO Q201.]

Q201 - ALL RESPONDENTS

Shape29

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[IF Q201/1 PROCEED TO Q300.]

[IF Q201/2,3 PROCEED TO Q202.]

Q202 - AWARE OF WEBSITE (Q201/2,3)

Shape30

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[IF Q201/2 PROCEED TO Q215.]

[IF Q201/3 PROCEED TO Q205.]

Q205 - HAVE VISITED WEBSITE (Q201/3)

Shape31

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[PROCEED TO Q210.]

Q210 - HAVE VISITED SITE (Q201/3)

Shape32

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[PROCEED TO Q215.]

Q215- EXPOSED TO CAMPAIGN (Q200/2 OR Q201/2,3 OR Q203/2,3 OR Q204/2)

Shape33

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[PROCEED TO Q220.]

Q220 - EXPOSED TO CAMPAIGN (Q200/2 OR Q201/2,3 OR Q203/2,3 OR Q204/2)

Shape34

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[IF CONSUMER (Q99/1) PROCEED TO Q300.]

[IF HCP (Q99/2) PRCOEED TO Q405.]

Q300 – CONSUMER SAMPLE (Q99/1)

Shape35

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[ALL PROCEED TO Q305.]

Q305 – CONSUMER SAMPLE (Q99/1)

Shape36

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[ALL PROCEED TO Q310.]

Q310 – CONSUMER SAMPLE (Q99/1)

Shape37

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[ALL PROCEED TO Q315.]

Q315 – CONSUMER SAMPLE (Q99/1)

Shape38

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[ALL PROCEED TO Q320.]

Q320 – CONSUMER SAMPLE (Q99/1)

Shape39

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[ALL PRCOEED TO Q335.]

Q335 – CONSUMER SAMPLE (Q99/1)

Shape40

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[ALL PROCEED TO Q340.]

Q340 – CONSUMER SAMPLE (Q99/1)

Shape41

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[ALL PROCEED TO dmStateUS.]

Q405 – HCP SAMPLE (Q99/2)

Shape42

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[ALL PROCEED TO Q410.]

Q410 – HCP SAMPLE (Q99/2)

Shape43

OMB Control Number: XXXX-XXXX Expiration Date: XX/XX/XXXX

[ALL PROCEED TO Q415.]

Q415 – HCP SAMPLE (Q99/2)

Shape44

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[ALL PROCEED TO Q420.]

Q420 – HCP SAMPLE (Q99/2)

Shape45

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[ALL PROCEEDT Q420.]

Q425 - – HCP SAMPLE (Q99/2)

Shape46

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[ALL PROCEED TO dmStateUS.]

Real Answer Check – QUALITY CHECK

Shape47

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[REAL ANSWER CHECK INSERTED ACCORDING TO QUALITY CHECK LOGIC.]

ISQ Check – QUALITY CHECK

Shape48

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[ISQ CHECK INSERTED ACCORDING TO QUALITY CHECK LOGIC.]

dmStateUS – ALL RESPONDENTS

Shape49

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[PROCEED TO dmZipUS.]

dmZipUS – ALL RESPONDENTS

Shape50

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[PROCEED TO dmEduUS.]

dmEduUS – ALL RESPONDENTS

Shape51

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[PROCEED TO dmMarStat.]

dmMarStat – ALL RESPONDENTS

Shape52

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[PROCEED TO dmAdultHh.]

dmAdultHh – ALL RESPONDENTS

Shape53

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[PROCEED TO dmChildHh.]

dmChildHh – ALL RESPONDENTS

Shape54

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[PROCEED TO dmHhIncUS.]

dmHhIncUS – ALL RESPONDENTS

Shape55

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

[PROCEED TO THANK YOU AND TERMINATE.]

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Andrew Walton
File Modified	0000-00-00
File Created	2021-07-05