Evaluation of a Prevention Information Prototype in the Context of a HRSA Community Health Center

Form Approved OMB No. 0990-0281

Exp. Date 08/31/2008

Pre Survey

Patient ID Number__________________________________________

Date _________________________

Directions:

Purpose: The information collected in this survey will be used by the US Department of Health and Human Services and Baltimore Medical System to improve health information for patients on prevention topics such as healthy eating and smoking cessation. We want to know if the information you receive through the Putting Prevention into Practice program supports you in making healthy decisions.

Participation: Your participation in this survey and any activity connected to this project is voluntary. You do not have to answer any question you don’t want to answer and you may stop at any time.

The information you provide will be linked to information from your health record. All information and forms you provide about yourself will be treated confidentially. Your name will not be associated with any of the information you provide in the survey below.

This project is sponsored by the U.S. Department of Health and Human Services. ICF International is helping to do this research. If you have any questions about this project, please call Sandy Hilfiker at (240) 453-8268.

Questions:

1. What topics are you interested in hearing about today? (Circle your choices)

   1. Smoking Cessation

   2. Weight Maintenance/Management (eating healthier and getting active)

   3. Both¹

2. How would you like to receive information? (You can circle as many as you want)

   1. Print information

   2. Look at a Web site in the exam room while you wait for a provider

   3. Receive follow-up call and information from BMS Outreach Staff

3. Would you be interested in hearing more about classes or counseling on either smoking cessation or weight management? □ Yes □ No

4. Do you have Internet access at home? □ Yes □ No

5. Do you feel comfortable using the Internet to find information about your health? □ Yes □ No

OMB BURDEN STATEMENT: 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 # 0990-0281. The time to complete this information collection is estimated to average 5 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.

6. If you smoke, how confident are you that you can take steps in the next month to quit

smoking? (Check the one box below that best describes you)

□ Completely □ Very □ Somewhat □ Not Very □ Not at
Confident Confident Confident Confident all Confident

7. How confident are you that you can take steps in the next month to manage your weight? (Check the one box below that best describes you)

□ Completely □ Very □ Somewhat □ Not Very □ Not at
Confident Confident Confident Confident all Confident

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