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

Post 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.

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.

Questions:

Place an “X” in the box that best describes your opinion

If you received quitting smoking information today:

	Completely Confident	Very Confident	Somewhat Confident	Not Very Confident	Not at all Confident
1) How confident are you that you can take a step in the next month to quit smoking?

	Completely Useful	Somewhat Useful	Useful	Not Very Useful	Not at all Useful
2) Did you find the information you received today on quitting smoking useful?

If you received weight management information today:

	Completely Confident	Very Confident	Somewhat Confident	Not Very Confident	Not at all Confident
1) How confident are you that you can take a step in the next month to better manage or maintain your weight

	Completely Useful	Somewhat Useful	Useful	Not Very Useful	Not at all Useful
2) Did you find the information you received today on managing your weight useful?

Additional Comments:

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