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pdfForm Approved
OMB No. 0990-0379
Exp. Date 06/03/2014
Voice-of-Customer Surveys
for HealthCare.gov
Site-Level Survey for Visitor Feedback
Introductory Text
Questions
1.
What were you looking for on HealthCare.gov today?
•
Find health insurance options
•
Learn how health insurance works
•
Learn about the Affordable Care Act
•
Compare health care providers
•
Get information about preventive services
•
Looking for information on Pre-Existing Condition Insurance Plan
•
Read the blog
•
Get news and updates about the Affordable Care Act
•
I had no agenda in mind when I came to the website today.
•
Other: ______________________
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0990-0379 . The time required to complete this information collection is estimated to average 5
minutes per response, including the time to review instructions, search existing data resources, gather the data
needed, and complete and review the information collection. If you have comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human
Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports
Clearance Officer
2.
Were you able to find what you were looking for?
•
Yes
•
Partially
•
No
[If Q2 response is YES]
3.
4.
How long did it take to find the information?
•
Immediately
•
Few minutes
• A long time
Did you find the information helpful?
•
Yes
•
Partially
•
No
[If Q4 response is YES]
5.
6.
7.
What did you like best about the content?
Based on today’s visit, how would you rate the following?
•
Overall site experience
•
Site design
• Ease of navigation
How can we improve HealthCare.gov?
[If Q4 response is PARTIALLY or NO]
5.
6.
7.
What can we do to make the information more helpful?
Based on today’s visit, how would you rate the following:
a. Overall site experience
b. Site design
c. Ease of navigation
What can we do to make HealthCare.gov better?
[If Q2 response is PARTIALLY or NO]
3.
4.
5.
What information were you looking for and did not find on HealthCare.gov?
Based on today’s visit, how would you rate the following:
a. Overall site experience
b. Site design
c. Ease of navigation
What can we do to make HealthCare.gov better?
Thank You Text
Site-Level Survey for Visitor Demographics
Introductory Text
Questions
1.
Are you:
•
2.
Female
• Male
How old are you?
•
Less than 12 years old
•
13-18 years old
•
18-26 years old
•
27-34 years old
•
35-49 years old
•
50-64 years old
•
Over 65 years old
3.
4.
5.
What is the highest level of education you completed?
•
Elementary school
•
Middle school
•
Some high school but did not finish
•
Completed high school
•
Some college but did not finish
•
Associate’s degree
•
Bachelor’s degree
•
Some graduate work
• Master’s or professional degree
Are you:
•
Single, never married
•
Married
•
Separated
•
Divorced
• Widowed
Do you have children?
•
Yes
•
No
[If Q5 response is YES]
6.
7.
How old are your children? Check all that apply.
•
Less than 5 years old
•
5-12 years old
•
13-18 years old
•
18-26 years old
•
27-34 years old
• Over 36 years old
Do you have a medical/health condition or a disability?
•
8.
Yes
• No
Do you have health insurance?
•
Yes, through my work
•
Yes, I pay for it myself
•
Yes, through a government program
•
No
[If Q5 response is NO]
6.
7.
Do you have a medical/health condition or a disability?
a. Yes
b. No
Do you have health insurance?
a.
b.
c.
d.
Yes, through my work
Yes, I pay for it myself
Yes, through a government program
No
Thank You Text
Page-Level Survey
Layout
Questions
1.
Was this page helpful?
•
Yes
•
No
[IF Q1 RESPONSE is YES]
2.
I found this page helpful because the content on the page: (check all that apply)
•
3.
Had the information I needed
•
Was trustworthy
•
Was up-to-date
•
Was written clearly
• Other: ____________________________
What can we do to improve this page?
[IF Q1 RESPONSE is NO]
2.
3.
I did not find this page helpful because the content on the page: (check all that apply)
a. Had too little information
b. Had too much information
c. Was confusing
d. Was out-of-date
e. Other: ____________________________
What can we do to improve this page?
| File Type | application/pdf |
| Author | Achaia Walton |
| File Modified | 2012-01-25 |
| File Created | 2012-01-25 |