Form #6 Form #6 Post-Visit Survey

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Thank you for your visit today to {Practice Name}!
When you are done with your visit, we would appreciate it you could complete a very brief survey.
You are being asked to complete the survey because you are between the ages of 12 and 18.
After you are done seeing the doctor, to complete the survey fill out the attached postcard and
give it to the front desk, or drop it in the mail.
This survey is designed to learn more about the computerized screener for adolescent patients.
This research is being paid for by the Agency for Healthcare Research and Quality (AHRQ).
This is an anonymous survey. Your responses will be kept confidential to the extent permitted
by law, including AHRQ’s confidentiality statute, 42 USC 299c-3(c).
You have a choice about completing the survey. You do not have to complete the survey if you
do not want to.
If you have questions, you can call Doug Fernald MA at 303-724-9705. You can call and ask
questions at any time.
You may have questions about your rights as someone in this study. If you have questions, you
can call COMIRB (the responsible Institutional Review Board). Their number is (303) 724-1055.
After your visit, please complete this anonymous survey
and return it to the front desk or place it in the mail.
Thank you!
Were you able to finish the computerized screener
before your saw the doctor?
Yes No
Was the computerized screener helpful in your
appointment today?
Yes No
Was your appointment today related in any way to the
“Colorado Clinics for Youth” Facebook page?
Yes No
What age are you? (Please check ONE answer)
 12
 13
 14
 15
 16
 17
 18
 None of above
Are you female or male?
 Female  Male
Please write in today’s Month and Year

Month: ________________
Year:

_______________

Public reporting burden for this collection of information is estimated to average 1 minute per
response, the estimated time required to complete the survey. 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. Form Approved: OMB Number 0935-XXXX Exp. Date
xx/xx/20xx. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden, to: AHRQ Reports
Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540
Gaither Road, Room # 5036, Rockville, MD 20850.