FSR 243 HHS SAMHSA Publications questionnaire

Customer Satisfaction Measure of Government Websites

FSR 243 HHS SAMHSA Publications.xls

FSR 224 DOD Marine Corps

OMB: 1505-0186

Document [xlsx]
Download: xlsx | pdf

Overview

Current Custom Qsts Online
Current Custom Qsts Followup


Sheet 1: Current Custom Qsts Online

Model Instance Name: red & strike-through: DELETE




SAMHSA OWH Publications Online Survey underlined & italicized: RE-ORDER




MID: pink: ADDITION




Date: 12/2/2008 blue + -->: REWORDING













SAMHSA OWH Publications Online Survey CUSTOM QUESTION LIST
QID Skip Logic Label Question Text Answer Choices
(limited to 50 characters)
Skip to Type (select from list) Single or Multi Required
Y/N
Special
Instructions


Which publication(s) did you view or order today? (please select only one choice below) "Action Steps for Improving Women's Mental Health" only
Drop down, select one S Y
"Women's Mental Health: What it means to you" only




Both






How did you hear about this publication(s)? (select all that apply) eBlast
Checkbox, one-up vertical M Y
Blog (please specify): A



SAMHSA news release




SAMHSA website




Womenshealth.gov website




Magazine or Newspaper




Radio or Television




Media and news releases




Web search/ websites




Exhibit or community event




Found them on site when ordering other material




Colleague




Friend




Other, please specify: B




A Blog

Text area, no char limit
N

B Other hear about

Text area, no char limit
N


Which of the publication(s) are you ordering for professional use? "Action Steps for Improving Women's Mental Health" only
Drop down, select one S Y
"Women's Mental Health: What it means to you" only




Both publications




Neither for professional use






How do you intend to use the publication(s) for professional use? (select all that apply) Direct distribution to patients/clients
Checkbox, one-up vertical M N
Teaching materials for professional students




Share with colleagues (professional education and distribution)




Self education/research




Give to community organization/faith-based organization/volunteer group




Public awareness campaign/event




Use within a classroom/youth setting




Other, please specify: A



Not applicable





A Other professional intent

Text area, no char limit
N


Which of the publication(s) are you ordering for personal use? "Action Steps for Improving Women's Mental Health" only A,B,C Drop down, select one S Y
"Women's Mental Health: What it means to you" only A,B,C



Both publications A,B,C



Neither for personal use





A Are you: Married/Living with partner
Drop down, select one S N
Single




Divorced/Separated




Widowed




Prefer not to answer





B Please select appropriate household income level: <$50,000
Drop down, select one S N
$50,000-$74,000




$75,000-$99,000




$100,000-$149,999




$150,000-$199,999




$200,000 or more




Prefer not to answer





C Would you be interested in having this publication(s) translated into any of these languages? (select all that apply) Spanish
Checkbox, one-up vertical M Y
Mandarin




Cantonese




French




Other, please specify: D




D Other language

Text area, no char limit
N


How do you intend to use the publication(s) for personal use? (select all that apply) Self education/research
Checkbox, one-up vertical M N
Give to family member/friend




Other, please specify: A



Not applicable





A Other personal intent

Text area, no char limit
N


What format do you prefer for publication(s) like this? Hard copy
Checkbox, one-up vertical S Y
Online PDF




Both hard copy and PDF format




Other, please specify: A




A Other format

Text area, no char limit
N


How would you rate your current level of awareness of women’s mental health? Extremely Aware
Radio button, one-up vertical S Y
Very Aware




Somewhat Aware




Not at all Aware






What is your occupation? Student
Checkbox, one-up vertical S Y
Program or service provider/worker




Clinician/medical professional




Educator/school teacher




Social worker/counselor




Consultant or Researcher




Policy advocate/lobbyist




Media/public relations professional/workers




Criminal justice/legal professional




Cleric/faith community teacher




Corporate finance/operations employee




Librarian/information worker




Not currently employed




Self-employed




Retired




Military/retired military




Other, please specify: A



Not applicable





A Other occupation

Text area, no char limit
N


What is your immediate workplace setting? Non-profit/community-based organization/coalition
Checkbox, one-up vertical S Y
School/university




Public place/interacting in community




Government office




Corporate office




Residential/in-patient facility




Church/faith-based organization




Non-residential/out-patient facility




Individual or group private practice




Client/patient home




Managed care/insurance company office




Other, please specify: A



Not applicable





A Other workplace

Text area, no char limit
N


What is your gender? Female
Drop down, select one S N
Male




Prefer not to answer






Please select your appropriate age range: <18 years old
Drop down, select one S N
18-24 years old




25-34 years old




35-44 years old




45-54 years old




55-64 years old




65 years and over




Prefer not to answer






Please select your appropriate Race/Ethnicity from the options below: Black/African American
Checkbox, one-up vertical S N
White




Hispanic or Latino




Asian American




Native Hawaiian or Other Pacific Islander




American Indian or Alaska Native




Other, please specify: A



Prefer not to answer





A Other race/ethnicity

Text area, no char limit
N


What is your highest level of schooling? Did not graduate from high school
Drop down, select one S N
High school graduate




Some college or vocation school




College graduate




Some post graduate schooling




Graduate or professional degree




Prefer not to answer






What is your state of residence? Alabama
Drop down, select one S N
Alaska




Arizona




Arkansas




California




Colorado




Connecticut




Delaware




Florida




Georgia




Hawaii




Idaho




Illinois




Indiana




Iowa




Kansas




Kentucky




Louisiana




Maine




Maryland




Massachusetts




Michigan




Minnesota




Mississippi




Missouri




Montana




Nebraska




Nevada




New Hampshire




New Jersey




New Mexico




New York




North Carolina




North Dakota




Ohio




Oklahoma




Oregon




Pennsylvania




Rhode Island




South Carolina




South Dakota




Tennessee




Texas




Utah




Vermont




Virginia




Washington




Washington D.C.




West Virginia




Wisconsin




Wyoming




Prefer not to answer






After you had some time to review the publication(s) you ordered today, we would like to contact you via email and get your feedback on them. If you would like to be contacted, please give us your email address here:

Text area, no char limit
N


Do you have any additional comments or feedback that you would like to share regarding the publication(s) you ordered? (please specify)

Text area, no char limit
N

Sheet 2: Current Custom Qsts Followup

Model Instance Name: red & strike-through: DELETE




SAMHSA OWH Publications Followup Email Survey underlined & italicized: RE-ORDER




MID: pink: ADDITION




Date: 12/2/2008 blue + -->: REWORDING













SAMHSA OWH Publications Followup Email Survey CUSTOM QUESTION LIST
QID Skip Logic Label Question Text Answer Choices
(limited to 50 characters)
Skip to Type (select from list) Single or Multi Required
Y/N
Special
Instructions


Which publication(s) did you order through the SAMHSA site? (please select only one choice below) "Action Steps for Improving Women's Mental Health" only
Drop down, select one S Y
"Women's Mental Health: What it means to you" only




Both






Which of the publication(s) did you order for professional use? "Action Steps for Improving Women's Mental Health" only
Drop down, select one S Y
"Women's Mental Health: What it means to you" only




Both publications




Neither for professional use






How did you use the publication(s) for professional use? (select all that apply) Direct distribution to patients/clients
Checkbox, one-up vertical M N
Teaching materials for professional students




Share with colleagues (professional education and distribution)




Self education/research




Give to community organization/faith-based organization/volunteer group




Public awareness campaign/event




Use within a classroom/youth setting




Other, please specify: A



Not applicable





A Other professional use

Text area, no char limit
N


Which of the publication(s) did you order for personal use? "Action Steps for Improving Women's Mental Health" only
Drop down, select one S Y
"Women's Mental Health: What it means to you" only




Both publications




Neither for personal use






How did you use the publication(s) for personal use? (select all that apply) Self education/research
Checkbox, one-up vertical M N
Give to family member/friend




Other, please specify: A



Not applicable





A Other personal use

Text area, no char limit
N


What format do you prefer for this publication(s) for your use? Hard copy
Checkbox, one-up vertical S Y
Online PDF




Both hard copy and PDF format




Other, please specify: A




A Other format

Text area, no char limit
N


Is there anything in the publication(s) that you were not able to understand? No
Checkbox, one-up vertical S Y
Yes, please specify: A




A Unable to understand

Text area, no char limit
N


Did you, or whomever you gave the publication(s) to, learn anything new as a result of reading this information? No
Checkbox, one-up vertical S Y
Yes, please specify: A



Not sure





A Learn anything new

Text area, no char limit
N


Did you, or whomever you gave the publication(s) to, take any specific action as a result of reading this information? No
Checkbox, one-up vertical S Y
Yes, please specify: A



Not sure





A Take any specific action

Text area, no char limit
N


How would you rate the ease of reading and understanding the publication(s)? Very Easy
Radio button, one-up vertical S Y
Somewhat Easy




Neutral




Somewhat Difficult




Very Difficult






How would you rate your current level of awareness of women’s mental health? Extremely Aware
Radio button, one-up vertical S Y
Very Aware




Somewhat Aware




Not at all Aware






How would you rate the overall importance of the publication(s) for you? Very Important
Radio button, one-up vertical S Y
Somewhat Important




Neutral




Not Very Important




Not at All Important






Will you continue to use this publication(s)? No
Checkbox, one-up vertical S Y
Yes, please specify how: A




A Continue to use

Text area, no char limit
N


Would you recommend this publication(s) to others? No
Checkbox, one-up vertical S Y
Yes, please specify why: A




A Recommend why

Text area, no char limit
N


Would you be interested in having this publication(s) translated into any of these languages? (select all that apply) Spanish
Checkbox, one-up vertical M Y
Mandarin




Cantonese




French




Other, please specify: A




A Other language

Text area, no char limit
N


Was there any information that you would have liked to have seen included in this publication(s) that we may include in the future? No
Checkbox, one-up vertical S Y
Yes, please specify: A




A Information included

Text area, no char limit
N


What other kinds of mental health-related information have you reviewed or researched in the past six months? (please specify)

Text area, no char limit
N


Where do you typically look for mental health-related information? (select all that apply) eBlast
Checkbox, one-up vertical M Y
Blog (please specify): A



This online site




Government-sponsored websites




Magazine or Newspaper




Radio or Television




Media and news releases




Web search/ websites




Exhibit or community event




Colleagues




Friend




Other, please specify: B




A Blog

Text area, no char limit
N

B Other source

Text area, no char limit
N


Do you have any additional comments or feedback that you would like to share regarding the publication(s) you ordered? (please specify)

Text area, no char limit
N
File Typeapplication/vnd.ms-excel
File TitleQuestionnaire Production Guidelines_Template
AuthorProfessional Services
Last Modified Bybjinnohara
File Modified2008-12-03
File Created2001-08-03

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