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

30-day Follow-Up Telephone Survey Questions

Hello, is this ______________________________________ ? Hi, my name is _______ and I work for ICF International. We are an independent health research organization working with the Baltimore Medical Systems’ Middlesex Health Center. We are calling you because you chose to participate in a wellness program at Middlesex Health Center. We are conducting a short follow up interview to better understand how to promote health and wellness. My questions will only take a couple of minutes. Do you have few minutes?

Before we begin, I’d like to explain a few things about the interview will work and what we will

with the answers we get from you today. Feel free to stop me to ask any questions you may have, okay?

This project is sponsored by the US Department of Health and Human Services. It is going to help them develop programs at health centers that can improve the health of patients.

The survey will take about 5 minutes and your participation is voluntary. You do not have to answer any question you don’t want to answer and you may stop at any time. We will not let anyone outside this project read your individual responses. Your name will not be associated with your answers to this survey. Whenever we report this data to the public, it will only be included with a much larger group of people who also participate in a telephone survey. At the end of this survey, I'll give you a phone number that you can use, if you have any questions or comments. Okay. Let’s begin

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 10 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.

Tobacco Cessation

1. You indicated that you wanted to quit smoking during your visit to Middlesex Health Center. Which of the following actions have you taken since then (check all that apply):

   1. called 1-800-QUIT-NOW for free support and to set up your quit plan (YES/NO)

   2. circled a quit date on your calendar. (YES/NO)

   3. did you stick to your quit date (YES/NO)

   4. made a shopping list with healthy snacks and sugar-free gum. (YES/NO)

2. Which of the following small changes did you make to help you quit?

   1. throwing away ashtrays (YES/NO)

   2. limit smoke breaks at work (YES/NO)

   3. don’t smoke in your home or car (YES/NO)

   4. ask your guests to smoke outside (YES/NO)

   5. smoked only outside when at home (YES/NO)

   6. OTHER ____________________________________________________________

3. If you still smoke, how confident are you that you can take steps in the next month to quit smoking? (Read

options and check the one box below that best describes the respondent’s choice)

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

4. Do you have Internet access at home? ____Yes [GO TO QUESTION 5] IF ____No  TERMINATE

5. Have you visited healthfinder.gov to learn more about quitting smoking? (YES/NO)

6. Was visiting healthfinder.gov helpful (1-5 scale with 5 being the most helpful)

Weight Management

7. You indicated that you wanted to manage your weight during your visit to Middlesex Health Center. Which of the following actions have you taken since then (check all that apply):

1. Visited the healthfinder ‘Get Started’ section on the Web site (or got handout at clinic)

(YES/NO)

2. Find out the number of calories you eat each week (using a calculator from healthfinder)

or from Msx. Handout (YES/NO)

3. Use a weight-loss log to keep track of how much you eat. (YES/NO)

4. Make a shopping list with healthy choices, such as: apples, baby carrots, low-fat or fat-

free yogurt, or whole-grain crackers (YES/NO)

5. Make an exercise plan for next week – and write it on your calendar. (YES/NO)

6. Actually exercised (YES/NO)

7. Drink water for a week instead of soda or juice (YES/NO)

8. Exercise while you are watching TV (YES/NO)

9. OTHER ____________________________________________________________

8. How confident are you that you can take steps in the next month to manage your weight? (Read options and check the one box below that best describes the respondent’s choice)

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

9. Do you have Internet access at home? ____Yes [GO TO QUESTION 10] IF ____No  TERMINATE

10. Have you visited healthfinder.gov to learn more about weight management? (YES/NO)

11. Was visiting healthfinder.gov helpful (1-5 scale with 5 being the most helpful)

READ: Thank you for participating in this survey.

INTERVIEWER NOTE:

If respondents have questions about the survey or its sponsorship, you should read:

“If you have any questions or comments you may call: Sandra Hilfiker, Public Health Advisor, Office of Disease Prevention and Health Promotion, 240-453-8268