Survey #3 Consumer Survey #3 Consumer View of Decision Aid

OMB No. 0930-0197
Expiration Date: XX/XX/XXXX

USER SATISFACTION SURVEY
on
DECISION AID ON ANTIPSYCHOTIC MEDICATIONS
for Mental Health Services Consumers
Thank you for taking the time to answer this survey about your experience with using
the computer-based Decision Aid on Antipsychotic Medications. We are interested in
whether the Decision Aid provided useful information about antipsychotic medications
and alternatives, whether it helped you think through a decision about use of
antipsychotic medications or alternatives, and whether it helped you discuss your
decision with a mental health service provider, if you did.
The results from this survey will be used to determine whether the Decision Aid is useful
for helping people make important decisions about antipsychotic medications and
alternative and complementary approaches, and whether it supports shared decisionmaking in mental health services.
Your participation is VOLUNTARY. You may choose to answer this survey or not. If
you choose not to, this will not affect any services you may be receiving.
The information you provide is kept PRIVATE. Your name will not be associated
with this survey. Other information that would let someone identify you will be kept
private. AHP will not share your personal answers with anyone. Reports that explain
the findings of this survey will reflect a collection of information from many participants.
This survey will be destroyed after data collection is completed.

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a
collection of information unless it displays a currently valid OMB control number. The OMB control number for
this project is 0930-0197. Public reporting burden for this collection of information is estimated to average 15
minutes per respondent per year, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to SAMHSA Reports Clearance Office, 1 Choke Cherry Road, Room 71044, Rockville, Maryland, 20857.

For Office
Use Only

Date:

Site:

OMB No. 0930-0197
Expiration Date: XX/XX/XXXX

Survey Instructions
You may be asked to skip over some questions in this survey. When this
happens you will see an arrow with a note that tells you what question to answer
next, like this:

Yes → If Yes, go to #1 on page 1
No

OMB No. 0930-0197
Expiration Date: XX/XX/XXXX

Questions
7. How long did it take you to complete the
Decision Aid?

Using the Decision Aid
1. Who, if anyone, assisted you when you
used the Decision Aid?

Less than half an hour
Between half an hour and one hour
Between one hour and two hours
More than two hours

No one - I used it on my own
Peer Support Staff
Therapist or Counselor
Doctor, Nurse, or Physician’s Assistant
Case Manager
Family member or friend
Other __________________

8. Did you find any of the supplemental
Cool Tools in the Decision Aid helpful?
Yes
No

2. Did you find the Decision Aid easy to
use?

9. Did you find any of the links to other
information or websites, such as peer
support programs, to be useful?

Yes
No

Yes
No

3. Did you have enough privacy when you
used the Decision Aid?

10. Would you use the Decision Aid again?

Yes
No

Yes
No

4. Did you find the Decision Aid helpful?

11. Would you recommend the Decision
Aid to others?

Yes
No

Yes
No

5. Did you use the Decision Aid to prepare
a written report?
Yes, preparing a report was helpful
Yes, but I did not find it helpful
No
6. Were you able to complete the Decision
Aid in one sitting?

Please continue on the next page

Yes
No

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OMB No. 0930-0197
Expiration Date: XX/XX/XXXX

Using the Decision Aid
12. For each statement below, mark the box that best describes your experience.
Not
at all

Statement

As a result of using the Decision Aid:
a. I know more about antipsychotic medications
b. I learned more about recovery and wellness
c. I thought about what is important to me
d. I realize I have a number of options
e. I identified my most serious concerns
f. I feel more confident about making my own decision
about antipsychotic medications
g. I felt prepared to talk to my provider
h. I learned more about peer support programs
i. I compared the side effects of different antipsychotic
medications
j. I know more about alternatives to antipsychotic
medications
k. I thought about watchful waiting
l. I felt less pressured about taking antipsychotic
medications
m. I know more about supplements that can be used in
addition to antipsychotic medications

Please continue on the next page

2

A
little

Some
what

Quite
a bit

Very
much

Does
Not
Apply

OMB No. 0930-0197
Expiration Date: XX/XX/XXXX

13. Have you met with a prescriber of
antipsychotic medications (for example, a
psychiatrist or a nurse practitioner) since you
used the Decision Aid?

18. When you think about the decision you
discussed with this provider, who did you want
this decision to be made by?
Provider should make the final decision
without considering my opinion

No → If No, go to #21 on page 5
Yes

Provider should make the final decision
after considering my opinion

Sharing Your Decision
Think about the decision that was made with the
medication prescriber in your meeting. For
example, this decision may have been for you to
simply continue on current medications, if any,
or it may have involved a change in medications
or mental health services. Keep this decision in
mind as you answer the following questions.

Provider and I should share responsibility
for the final decision
I should make the final decision after
considering provider’s opinion
I should make the final decision without
considering provider’s opinion

14. What type of provider did you meet with?

Not sure

Psychiatrist or other M.D.
Nurse
Physician’s Assistant
Other____________________
Not sure

19. When you think about the decision you
discussed with this provider, who was this
decision actually made by?
Provider made the final decision without
considering my opinion

15. How long have you been meeting with this
provider?

Provider made the final decision after
considering my opinion

This is the first time
Less than two months
More than two months but less than one year
One year or more

Provider and I shared responsibility for
the final decision

16. Did you give the provider the written report
you prepared with the Decision Aid?

I made the final decision after considering
the provider’s opinion

Yes
No
Not applicable

I made the final decision without
considering the provider’s opinion
Not sure

17. Did the provider review your written report
either before or during your meeting?

Decision has not been made

Yes
No
Not applicable or not sure

Please continue on the next page
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OMB No. 0930-0197
Expiration Date: XX/XX/XXXX

Instructions: Think about the meeting you had with the medication prescriber as you complete the two
sets of statements below.
20. For each statement below, mark the box that best describes your experience.
Not
at all

Statement

A
little

As a result of using the Decision Aid:
a. I felt more confident about asking questions about
antipsychotic medications
b. I told the provider what is important to me
c. I asked the provider for information about alternatives to
antipsychotic medications
d. I was more confident about discussing difficult topics
with the provider
e. The provider and I discussed a number of options
f. I told the provider what bothers me about antipsychotic
medications
g. The provider and I developed a plan that I can follow
h. I realized I found it hard to talk about my concerns with
this provider
i. I told the provider how my beliefs affect my decisions
about medications and other mental health services

As a result of using the Decision Aid, I felt that the provider:
j. Talked with me about the possible advantages and side
effects of one antipsychotic medication compared to others
k. Supported my right to make my own decision about
anti-psychotic medications
l. Understood what is important to me
m. Talked with me about alternatives to antipsychotic
medications
Please continue on the next page
4

Some
what

Quite
a bit

Very
much

Does
Not
Apply

OMB No. 0930-0197
Expiration Date: XX/XX/XXXX

21. Have you discussed what you were
considering when you used the Decision Aid
with a mental health services provider who
is not a prescriber of antipsychotic
medications (for example, a therapist or case
manager)?

25. Did the provider review your written
report either before or during your meeting?
Yes
No
Not applicable or not sure

No → If No, go to #27 on page 7
Yes

Discussing Your Decision
Think about your meeting with this service
provider as you answer the following
questions.
22. What type of provider did you meet
with?
Therapist or Counselor
Case Manager
Peer Support Staff
Other____________________
Not sure
23. How long have you been meeting with
this provider?
This is the first time
Less than two months
More than two months but less than
one year
One year or more
24. Did you give the provider the written
report you prepared with the Decision Aid?
Yes
No
Not applicable

Please continue on the next page

5

OMB No. 0930-0197
Expiration Date: XX/XX/XXXX

Instructions: Think about the meeting you had with this provider as you complete the two sets of
statements below.
26. For each statement below, mark the box that best describes your experience.
Not
at all

Statement

A
little

As a result of using the Decision Aid:
a. I felt more confident about asking questions about
antipsychotic medications
b. I told the provider what is important to me
c. I asked the provider for information about alternatives to
antipsychotic medications
d. I was more confident about discussing difficult topics
with the provider
e. The provider and I discussed a number of options
f. I told the provider what bothers me about antipsychotic
medications
g. The provider and I developed a plan that I can follow
h. I realized I found it hard to talk about my concerns with
this provider
i. I told the provider how my beliefs affect my decisions
about medications and other mental health services

As a result of using the Decision Aid, I felt that the provider:
j. Talked with me about the possible advantages and
disadvantages of mental health services and alternatives
k. Supported my right to make my own decision about my
mental health services
l. Understood what is important to me
m. Talked with me about alternatives to antipsychotic
medications
Please continue on the next page
6

Some
what

Quite
a bit

Very
much

Does
Not
Apply

OMB No. 0930-0197
Expiration Date: XX/XX/XXXX

About You

34. How much education did you complete?

27. How much experience have you had
using a computer?

Less than High School
High School or GED
Some college
College graduate or more

No experience
Some experience
A lot of experience

35. What is your current employment
status?

28. How comfortable are you with using a
computer?

Employed full-time
Employed part-time
Not employed

Not at all comfortable
Somewhat comfortable
Very comfortable

36. How long have you been receiving
mental health services?

29. Were you comfortable putting your
personal information in the Decision Aid?

This is the first time
Less than one year
Between one and five years
More than five years

Not at all comfortable
Somewhat comfortable
Very comfortable

37. How long have you been taking antipsychotic medication?

30. What is your gender?
Female
Male

This is the first time
Less than one year
Between one and five years
More than five years
I have never taken antipsychotic medication

31. How old are you?
__________ years

38. What information have you seen or
heard about Shared Decision-Making?

32. Are you of Hispanic or Latino origin?
Yes
No

Presentation
Brochure
Video
Internet
Journal or Newspaper Article
Other_____________________
I have not heard about Shared
Decision-Making

33. What is your race? Mark all that apply.
American Indian/Alaskan Native
Asian
Black or African-American
Native Hawaiian or other Pacific
Islander
White

Please continue on the next page
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OMB No. 0930-0197
Expiration Date: XX/XX/XXXX

39. Have you ever used the What Is Right
For Me Workbook to help you make a
decision?
Yes
No
40. Is there anything else you think we
should know about your experience using
the Decision Aid?
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________

You have completed the survey.
Thank you for your participation!

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