FSR 243 HHS SAMHSA Publications questionnaire

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Overview

Current Custom Qsts Online
Current Custom Qsts Followup

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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

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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