Form 001_BFWHWEmWellCon

Bright Futures for Women’s Health and Wellness (BFWHW) Initiative
Consumer Survey
DRAFT
Please answer the following questions by checking the circle or circles next to your answer: Please pick one
answer for each question.
1. How old were you on your last birthday?
 13-17
 18-24
 25-44
 45-64
 65+
2. Are you Hispanic or Latina?
 Yes
 No
3. Which one of the following would you say is
your race?
 White
 Black
 American Indian or Alaska Native
 Asian
 Native Hawaiian or other Pacific Islander
 Two or more races
4. What is the highest level of education you
have completed?
 Eighth grade or less
 Some High School
 High School/GED (General Educational
Development)
 Some College, technical or trade school
 College Degree
 Graduate Degree
5. What is your marital status?
 Single, never married
 Married
 Living with Partner/Cohabitating
 Separated/Divorced
 Widowed
6. About how many times in the last 12 months
have you had an appointment with this clinic
for health care or other services?
0
 1-3
 4-6

 More than 6

7. What types of services were you seeking
here today (check all that apply)?
 Prenatal/maternity care
 Routine check-up
 Treatment for illness
 Emotional health counseling
 Support group
 Other_______________________
8. What is your overall satisfaction with
receiving services from this clinic?
 Very satisfied
 Mostly satisfied
 A little satisfied
 Mostly unsatisfied
 Very unsatisfied
9. How comfortable are you talking to doctors
and other health care providers about your
emotional health and wellbeing?
 Very comfortable
 Mostly comfortable
 A little comfortable
 A little uncomfortable
 Very uncomfortable
10. In the last 12 months, about how many times
have you talked about your emotional health
and well-being with a doctor, counselor or
other health care provider?
0
 1-3
 4-6
 More than 6
11. How happy, satisfied, or pleased have you
been with your personal life over the last
month?

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 0915-xxxx.
Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time
for reviewing instructions, searching existing data sources, 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 HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.

 Extremely happy, could not have been
more satisfied or pleased
 Very happy most of the time
 Generally happy, pleased
 Sometimes fairly satisfied, sometimes
fairly unhappy
 Generally dissatisfied, unhappy
 Very dissatisfied, unhappy most of the
time
12. During the past month, how much of the
time has your daily life been full of things
that were interesting to you?
 All of the time
 Most of the time
 A good bit of the time
 Some of the time
 A little of the time
 None of the time
13. During the past month, how often did you
feel there were people you were close to?
 Always
 Very often
 Fairly often
 Sometimes
 Almost never
 Never
14. Have you been given a copy of the BFWHW
Emotional Wellness Guide (either the Young
Women’s or the Women’s Guide)?
 Yes
 No
 Unsure
If you answered “Yes” to Question #14, please
answer the rest of the questions on this survey..
If you answered “No”or “Unsure” to Question
#14, please only answer question #22.
15. Did you read all or part of the BFWHW
Emotional Wellness Guide?
 All of it
 Part of it
 Just skimmed it
 No

16. How easy is the BFWHW Emotional
Wellness Guide to read and understand?
 Very easy to read and understand
 Mostly easy to read and understand
 A little easy to read and understand
 A little hard to read and understand
 Very hard to read and understand
17. Do you think the BFWHW Emotional
Wellness Guide contains advice that you can
use to feel better about your life?
 Yes, it contains very useful advice
 Yes, it contains mostly useful advice
 No, the advice is not useful
 Unsure
18. Did the personal stories and examples in the
BFWHW Emotional Wellness Guide seem
familiar to you or relate to your own life?
 Yes, very related
 A little related
 Not very related
 Not related at all
 Unsure
19. Would you share or recommend the
BFWHW Emotional Wellness Guide to
friends or family members?
 I would recommend it to a friend or
family member
 I would not recommend it to a friend or
family member
 Unsure
20. Now that you have been given the BFWHW
Emotional Wellness Guide, are you more or
less likely to talk about your emotional
health and well-being with your doctor,
counselor or another health care provider?
 More likely
 Less likely
 No difference
 Unsure

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 0915-xxxx.
Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time
for reviewing instructions, searching existing data sources, 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 HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.

21. Please write down any other comments you
have about the BFWHW Emotional Wellness
Guide that you would like to share:

22. Would you be interested in more
information about how to improve your
emotional health and wellbeing?
 Yes
 No

Thank you for your participation!

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 0915-xxxx.
Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time
for reviewing instructions, searching existing data sources, 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 HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.