Sample Demographic and Screening Questions
Are you male or female?
Male
Female
How old are you?
17 years old or younger
18-24 years old
25-34 years old
35-49 years old
50-64 years old
65 years old or older
What is your highest level of education?
GED
High school diploma
Associates degree
4-year degree
Bachelors
Masters
Graduate degree
Post-graduate degree
Doctoral degree
Other: _________
What is your country of origin?
How would you describe your race?
American Indian or Alaska Native
Asian, Native Hawaiian, or Other Pacific Islander
Black or African-American
Hispanic or Latino
White or Caucasian
Don’t Know/Prefer not to answer
What is (are) your primary language(s)?
What languages would you like to see represented on the CDC Web site?
In what country do you live?
If you are in the USA, in which city (also give state or territory) do you live?
Would you describe the area in which you live as rural or urban?
Rural
Urban
I don’t know
Are you a CDC employee, contractor, or fellow?
What is your profession?
Attorney or other Legal Professional
Business Owner or Operator
CDC Employee or Contractor
CDC Partner
Disease carrier or survivor
Epidemiologist
Farmer
General public
Health Communication
Health Education
Health Administration
Healthcare provider (physician, nurse, physician’s assistant, nurse practitioner)
Media
Medical or Scientific researcher
Medicine
Mother/Primary Caregiver
Non-Health Care Related
Nurse/Advanced Practice Nurse
Other Health Care Professional: ________
Pharmacy, Physician Assistant
Policy maker or their staff
Program Grantee
Public Health Communication Specialist
Public Health Educator
Public Health Worker
Retired
Staff at Hospital or Clinic
Student (Medicine and Allied Health Professions)
Student (non-Medicine and non-Allied Health Professions)
Teacher/Educator
[insert health topic specific job/role]
[insert health topic specific job/role]
[insert health topic specific job/role]
[insert health topic specific job/role]
Other: _____________
Who is your employer?
Agriculture Industry
Clinic
Community Based Organization (CBO)
Correctional Institution
Federal Agency (not military)
Health-Related Professional Association/Organization
Homeless Shelter
Hospital
International
Medical or Allied Health School or Library
Military
National Model [insert health topic] Center
Non-Health Related Business/Industry
Non-profit Organization
Nursing Home, Drug
Private Sector Health Care Provider
Private Sector non-Health Care Provider
State/Local Health Department
Student
Treatment Facility
Other: __________
What is your job title?
Please describe your job role:
How long have you worked in your current profession?
Less than one year
1 year
2 – 5 years
6 – 10 years
More than 10 years
On average, how much time do you spend using a computer each day?
More than 4 hours a day
1 – 4 hours a day
Less than 1 hour a day
What type of computer do you use most often?
PC
Mac
Other
Please describe:
Where do you use your computer most often?
At Home
At Work
At School
At friend’s/relative’s
At library
Other
Please describe:
How would you rate your computer experience?
Novice – I am new to computers and/or I only use one for a specific purpose
Low – I am somewhat new to computers and/or I am relatively comfortable with one or two software applications/programs (e.g. Microsoft Word, Excel, etc.).
Intermediate – I am comfortable with computers and/or I have learned and use between three and ten different software applications/programs.
Expert – I know my way around computers and/or I am comfortable troubleshooting most of the problems that arise with computers and/or I have used many different software applications and have some programming skills.
In general, what are the most frequent computer-related activities you do? (check all that apply)
Internet/Intranet
Software programs/applications. Please describe:
Other: __________
Are you currently a CDC employee, full-time contractor, part-time contractor, or fellow?
Response options: ‘yes’, ‘no’
Sample Knowledge, Attitude, and Behavior questions
Specific [insert health topic] information for myself
Specific [insert health topic] information for someone else (loved one, family member, patient, client, etc.)
Vaccination information
Professional training/education materials
Patient education materials
Clinical information/resources
Hospitals, doctors offices, or clinics located near me
Symptoms
Treatment
Prevention
Data or statistics
Registries and Surveillance
Fact Sheets
Partners
Events
Training
Outbreak information
Publications
Health Disparities
Legislation
Diagnostic tools/aids
Information in other languages
Program information
Research activities (intramural and extramural)
News
Funding opportunities
Recommendations/Guidelines
Meeting/Conference information
Caregiver resources
Partner/Other Organization opportunities and resources
Best Practices/Success Stories
General Health Information including prevention and/or treatment
Other (please specify): ______________________________
Where do you typically acquire [insert health topic] information?
Internet/Web
Radio
T.V.
Journal articles
Textbooks
Library
Brochures, Pamphlets
Healthcare provider
Friend
Family
Online library
Online journals
Listservs
Newsletters
Magazines
Newspapers
Don’t consult sources
Other: _______
If you need information about [insert health, communication, or marketing topic/challenge], where do you generally look first?
Overall, how satisfied are you with [insert respondent’s response] as an information source?
extremely satisfied
very satisfied
satisfied
not very satisfied
extremely unsatisfied
What do you like most about [insert respondent’s response]?
What do you like least about [insert respondent’s response]?
How useful is [insert respondent’s response] as an information source?
extremely useful
very useful
useful
not very useful
extremely not useful
Have you ever used [insert CDC program/product/service of interest]?
If yes…
What was the reason you used [insert CDC program/product/service of interest]?
How recently have you used [insert CDC program/product/service of interest]:
within the last week
within the last month
within the last six months
within the last year
over one year ago
How frequently do you use [insert CDC program/product/service of interest]:
Daily
Weekly
Monthly
Yearly
every couple of years
What do you like about [insert CDC program/product/service of interest]?
What do you not like about [insert CDC program/product/service of interest]?
Overall, how would you rate your experience with [insert CDC program/product/service of interest]?
very positive
positive
so-so
negative
very negative
Please tell me a little more about why your experience was [insert respondent’s rating answer]?
If no…
What do you think [insert CDC program/product/service in question] is?
Who do you think [insert CDC program/product/service in question] is for?
Are you planning to use [insert program/product/service in question]:
in the next month
in the next 2 to 3 months
in the next 4 to 6 months
in the next year
never
If any answer except ‘never’…
Please tell me a little more about why you plan to use [insert program/product/service in question] in the future?
How would you rate your knowledge about [insert description of health, communications, or marketing challenge]?
novice - I am new to and/or I am not comfortable with [insert description of health, communications, or marketing challenge].’
Intermediate – I am comfortable with and/or I generally know how to approach [insert description of health, communications, or marketing challenge].’
Expert – I am completely comfortable [insert description of health, communications, or marketing challenge].’
How would you rate your level of experience with [insert description of health, communications, or marketing challenge]?
novice - I am new at [insert description of health, communications, or marketing challenge].’
low – I am somewhat new at [insert description of health, communications, or marketing challenge].’
intermediate – I am comfortable with [insert description of health, communications, or marketing challenge].’
expert – I am confident with[insert description of health, communications, or marketing challenge].’
Did using [insert CDC program/product/service in question] require any new skills?
Yes
No
If yes, please explain
How likely are you to use [insert CDC program/product/service in question] for [insert usage purpose reported by respondent] again in the future?
Extremely likely
Somewhat likely
Somewhat unlikely
Extremely unlikely
If any answer except ‘extremely unlikely’,
How soon do you anticipate using [insert CDC program/product/service in question] again?
in the next month
in the next 2 to 3 months
in the next 4 to 6 months
in the next year
How likely are you to use [insert CDC program/product/service in question] for some reason other than for [insert usage purpose reported by respondent] in the future?
Extremely likely
Somewhat likely
Somewhat unlikely
Extremely unlikely
If any answer except ‘extremely unlikely’,
How soon do you anticipate using [insert CDC program/product/service in question] for this purpose?
in the next month
in the next 2 to 3 months
in the next 4 to 6 months
in the next year
Which of the following organizations are you familiar with? Please answer yes if you have heard of the organization, or no if you have not.
The Food and Drug Administration (FDA)
The Centers for Disease Control and Prevention (CDC)
The US Department of Agriculture (USDA)
The Environmental Protection Agency (EPA)
The Department of Homeland Security (DHS)
The Transportation Security Administration (TSA)
The National Institutes of Health (NIH)
National Institute for Occupational Safety and Health (NIOSH)
Occupational Safety and Health Administration (OSHA)
World Health Organization
The American Cancer Society
The American Heart Association
American Medical Association
Please say for each if you understand what it is and does, or not. Please answer yes if you know what the organization does, no if you do not, or not sure if you are not sure.
The Food and Drug Administration (FDA)
The Centers for Disease Control and Prevention (CDC)
The US Department of Agriculture (USDA)
The Environmental Protection Agency (EPA)
The Department of Homeland Security (DHS)
The Transportation Security Administration (TSA)
The National Institutes of Health (NIH)
National Institute for Occupational Safety and Health (NIOSH)
Occupational Safety and Health Administration (OSHA)
World Health Organization
The American Cancer Society
The American Heart Association
American Medical Association
Overall, how would you rate the job [organization] does - – excellent, pretty good, only fair or poor?
The Food and Drug Administration (FDA)
The Centers for Disease Control and Prevention (CDC)
The US Department of Agriculture (USDA)
The Environmental Protection Agency (EPA)
The Department of Homeland Security (DHS)
The Transportation Security Administration (TSA)
The National Institutes of Health (NIH)
National Institute for Occupational Safety and Health (NIOSH)
Occupational Safety and Health Administration (OSHA)
World Health Organization
The American Cancer Society
The American Heart Association
American Medical Association
In what health areas does the Centers for Disease Control and Prevention (CDC) do research or conduct programs? Please answer yes, no, or not sure to each.
Infectious diseases (like flu, AIDS/HIV, or the ebola virus)
Chronic diseases (like cancer, heart disease, or diabetes)
Injuries and violence (like domestic abuse, head injuries or vehicle collisions)
Childhood and adult immunizations (like for the flu, measles, and hepatitis)
Illnesses caused by the environment (like asthma or lead poisoning)
Workplace-related illnesses (back injuries, hearing loss, or black lung disease)
Tracking and monitoring diseases
Training Public Health Workers
Please answer (yes, no, not sure) each of the following items regarding the CDC:
I have a good understanding of what CDC does.
CDC protects America by fighting epidemics and disease outbreaks.
CDC works only in the U.S. – not in other countries.
CDC is one of the first places I would turn to for reliable health information.
CDC treats patients with complicated medical problems.
CDC helps make America safer.
CDC usually works alone – not with local and state organizations (like the March of Dimes, schools, or health departments).
One of the health information sources I trust most is the CDC.
Open-Ended questions
When you think about [insert CDC program/product/service in question], what are the first three things that come to mind?
Please tell me a little more about why you say [insert respondent’s response].
What do you like most about [insert CDC program/product/service in question]?
What do you like least about [insert CDC program/product/service in question]?
Is [insert CDC program/product/service in question] for you? Do you think it would be better for someone else? Who? Why?
In your opinion, does/would [insert CDC program/product/service in question] meet your needs?
Please tell me a little more about why you say [insert respondent’s response].
Are any ways in which [insert CDC program/product/service in question] can be improved?
In your opinion, does/would [insert CDC program/product/service in question] prompt you to [insert description of specific behavior being encouraged]?
Please tell me a little more about why you say [insert respondent’s response].
Are any ways in which [insert CDC program/product/service in question] could be modified to be more motivational or encouraging?
What did you like most about your experience acquiring [insert CDC program/product/service in question]?
What did you like least about your experience acquiring [insert CDC program/product/service in question]?
Is there anything you think should be included in [insert CDC program/product/service in question] that does not currently exist?
Please share any suggestions you have for improving the design of [insert CDC program/product/service in question]?
Please share any suggestions you have for improving the usability of [insert CDC program/product/service in question]?
What was the main purpose of your using [insert CDC program/product/service in question]?
What, if anything, did you learn by using [insert CDC program/product/service in question]?
What surprised you the most about your overall experience using [insert CDC program/product/service in question]?
What surprised you the least about your experience using [insert CDC program/product/service in question]?
What did you expect from [insert CDC program/product/service in question] that disappointed you when you found it was unavailable?
What would you like to see from [insert CDC program/product/service in question] in the future?
How useful was [insert CDC program/product/service in question]?
Is the [insert CDC program/product/service in question] up to date?
Who do you think would find [insert CDC program/product/service in question] most useful?
What is the best way to inform other [user type] that [insert CDC program/product/service in question] exists?
In 2-3 brief sentences, please describe your experience with [insert CDC program/product/service in question]
What’s the biggest barrier/challenge to using [insert CDC program/product/service in question]?
Is there anything that might make it easier to use [insert CDC program/product/service in question]?
What are the three most important things CDC can do to improve the delivery of [insert CDC program/product/service in question] in the future?
Would you recommend [insert CDC program/product/service in question] to anyone? Who? Why?
Please describe any programs, products, or services you would like to have or like to be able to use to address [insert health, communication, or marketing topic/challenge] that are currently unavailable to you.
How would [insert program, product, or service identified by respondent] help you?
If [insert program, product, or service identified by respondent] were developed, why would it be beneficial?
Are there any potential problems or challenges you might foresee with [insert program, product, or service identified by respondent]? Please explain why you think these problems or challenges might arise.
In what aspect of your job does [insert CDC program/product/service in question] assist you the most?
I want you to think about a time when you [insert description of health, communication, or marketing topic/challenge].
What was good about the experience?
What was not so good?
I want to understand how decisions are made in your group/organization about which program, product, or service to use to address [insert health, communication, or marketing topic/challenge]. Who are the primary people you interact with? How? Why?
Explain to me the step involved in adopting a program, product, or service to address [insert health, communication, or marketing topic/challenge]. Where or from whom do you need to obtain approval?
How would you describe your role with regard to [insert health, communication, or marketing topic/challenge]?
Is there anything that would make it more useful?
What types of programs, products or services do you typically use to address [insert health, communication, or marketing topic/challenge]?
What types of programs, products or services do you rarely use to address [insert health, communication, or marketing topic/challenge]?
In your opinion, what makes [insert respondent’s response for program/product/service used regularly] more appealing than [insert respondent’s response for program/product/service rarely used]?
If you were going to design a program/product/service to address [insert description of health, communications, or marketing challenge], what key features would it need to have?
In your opinion, why are these features important to include?
Customer Service
How satisfied are you with the following customer service aspects of [insert CDC program/product/service in question]’s delivery?
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How would you rate the following aspects of [insert CDC program/product/service in question]’s delivery?
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Not Applicable |
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Not Applicable |
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| File Type | application/msword |
| Author | ftm3 |
| Last Modified By | Jill B Surrency |
| File Modified | 2008-04-24 |
| File Created | 2007-12-20 |