eConsent Evaluation Survey

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

ONCeConsentFastTrackSurvey

eConsent Evaluation Survey

OMB: 0990-0379

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The following is the list of questions for the eConsent Evaluation Survey:


  1. HOW (CONTEXT) – I was just asked to make a consent decision about whether my health information can be accessed by my health care providers through a:

Health Information Exchange Electronic Health Record HIPAA I am not sure



  1. WHAT – My tests results may be accessed through HEALTHeLINK:

True False I am not sure



  1. WHAT – Some sensitive health information like substance use information may be accessed through HEALTHeLINK:

True False I am not sure



  1. WHO – If I give consent, health care providers involved in my care can access my health information through HEALTHeLINK:

True False I am not sure



  1. WHO – If I do not make a consent decision, in an emergency situation, health care providers involved in my care will be able to access my health information through HEALTHeLINK:

True False I am not sure



  1. HOW (SECURITY/PROTECTION) – There are penalties for persons and organizations who improperly access or use my health information through HEALTHeLINK:

True False I am not sure



  1. The information I just viewed was easy to understand:

Completely Disagree Partially Disagree Neutral Partially Agree Completely Agree


  1. The information I received today helped me make my decision about the consent options:

Completely Disagree Partially Disagree Neutral Partially Agree Completely Agree


  1. The tablet device was easy to use:

Completely Disagree Partially Disagree Neutral Partially Agree Completely Agree


  1. The time it took me to view the information and make my consent decision was:

Completely Too Long A Little Too Long Just Right A Little Too Short Completely Too Short


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorHHS
File Modified0000-00-00
File Created2021-02-01

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