Form FSR 216 FSR 216 VA MyHealtheVet
Customer Satisfaction Measure of Government Websites
FSR 216 VA MyHealtheVet questionnaire.xls
FSR 216 VA MyHealtheVet, FSR 217 USDA NRRS Recreation.gov, FSR 218 TREAS IRS
OMB: 1505-0186
⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1505-0186 can be found here:
Document [xlsx]
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Custom Qsts
Overview
Model QstsCustom Qsts
Sheet 1: Model Qsts
Sheet 2: Custom Qsts
| PROPOSED CUSTOM QUESTIONS FOR MyHealtheVet Custom questions complement the model questions and allow for additional data analysis |
|||||
| Question Text | Answer Choices (limited to 50 characters) |
Type drop-down menu check boxes radio buttons open-ended |
Required Y/N |
Select one or all that apply | |
| How frequently do you visit the My HealtheVet web site? | First time Daily More than once a day About once a week About once a month About every 3 months About every 6 months Less than every 6 months |
Drop-down menu | Y | select one | |
| What best describes you? | Active duty Veteran Family member of a veteran Veteran service organization News media General public VA employee Federal government employee State/local government employee Other (please specify): |
Radio buttons | Y | select one | |
| If applicable, please indicate your military period(s) of service: | Operation Enduring Freedom/Iraqi Freedom Gulf War Vietnam Era Korean Conflict World War II World War I Peacetime Service |
check boxes | N | select all that apply | |
| What were you trying to accomplish today in My HealtheVet? (please select all that apply) | Enter/keep track of personal information (My Caregivers, etc.) Enter/keep track of personal health care information (blood pressure, blood sugar, etc.) Look up information about a medication Request a prescription refill Access prescription history from my VA medical record Find a VA health care facility Research a health condition Find information about VA Benefits Other (please specify): |
check boxes | Y | select all that apply | |
| How were you trying to locate this information? (please select all that apply) | Browsing (following links in page) Search engine Top navigation bar Quick links Site map Other |
check boxes | Y | select all that apply | |
| Did you accomplish what you wanted to in My HealtheVet? | Yes No Partially |
Drop-down menu | Y | select one | |
| If you did not accomplish what you wanted to in My HealtheVet, please specify what you wanted to do. | Open-ended | N | |||
| If you have utilized any of the following My HealtheVet features, which, if any, did you find particularly useful? Which, if any, have you had difficulty using? | Health Education Libraries & Condition Centers (Research Health) Personal Health Care Information (such as Caregivers, Treatment Facilities, etc.) Online Prescription Refill Requests (Pharmacy) My Medications & Supplements (Self-entered, Pharmacy) My Complete Medications List (combined view of both VA and self-entered) Health Calendar (Get Care) HealtheLogs (self-entered, such as Vitals, Tests, Allergies, etc.) Health History (personal, family, or military health history) Personal Health Summary (Track Health) |
Drop-down menu | N | select one | |
| What additional services would you like to see on My HealtheVet? (please select all that apply) | View upcoming appointments Schedule or change appointments Communicate electronically with my doctor Access to my medical record information Delegate access to my personal health record to another person Wellness reminders Drug interaction checking Opt-in monthly email newsletter Advance check in for clinic visits Educational programs Provider report card Notification of new content/features on the site Other (please specify): |
check boxes | N | select all that apply | |
| What is your age range? | 18 or under 19 - 30 31 - 40 41 - 50 51 - 60 61 - 70 71 or older |
Drop-down menu | N | select one | |
| Are you a registered user on the MyHealtheVet web site? | Yes No Not sure |
Drop-down menu | Y | select one | |
| Have you visited your VA Facility in person to show your ID and be "in-person authenticated" (IPA) for My HealtheVet? | Yes No Not sure Not applicable |
Drop-down menu | Y | select one | |
| If not, why have you not been "In-Person Authenticated"? | Open-ended | N | |||
| Did you take part in a pilot project for the My HealtheVet web site? | Yes No Not sure |
Drop-down menu | Y | select one | |
| My use of the My HealtheVet personal health record has improved my ability to manage my health. | Strongly agree, Agree, Not sure, Disagree, Strongly disagree, Not applicable | Drop-down menu | Y | select one | |
| What is the main improvement that you would suggest for the My HealtheVet web site? | Open-ended | N | |||
| File Type | application/vnd.ms-excel |
| Author | Professional Services |
| Last Modified By | FCG |
| File Modified | 2007-10-10 |
| File Created | 2001-08-03 |
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