491 HHS Civ Rights 491 HHS Office of Civil Rights

Model Instance Name

red & strike-through: DELETE

HHS OCR

underlined & italicized: RE-ORDER

MID: doQhU1ZZoUowo8IpohgEJg==

pink: ADDITION

Date:

9/15/2011

blue + -->: REWORDING

HHS OCR CUSTOM QUESTION LIST

QID

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Question Text

AnswerIDs (DOT)

Answer Choices (limited to 50 characters)

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Type (select from list)

Single or Multi

Required Y/N

Special Instructions

CQ Label

SAC4713

How frequently do you visit this site?

SAC4713A001

This is my first time visiting the site

Radio button, one-up vertical

Single

Y

Frequency of Visit

SAC4713A002

Daily

SAC4713A003

About once a week

SAC4713A004

About once a month

SAC4713A005

Every few months

SAC4713A006

Every 6 months or less often

SAC4714

What best describes your role in visiting the site today?

SAC4714A001

General Public

Radio button, one-up vertical

Single

Y

Skip Logic Group

Primary Role

SAC4714A002

Health Care Professional

SAC4714A003

Human Services Professional

SAC4714A004

HIPAA Covered Health Care Provider (health care provider that conducts certain transactions electronically)

SAC4714A005

Health Care Clearinghouse

SAC4714A006

Health Plan Provider(Health insurance companies, HMOs, Company health plans, Government programs that pay for health care, such as Medicare, Medicaid, and the military and veterans health care programs)

SAC4714A007

HIPAA Business Associate

SAC4714A008

Federal Government

SAC4714A009

State/Local/Tribal Government

SAC4714A010

Consultant/Legal

SAC4714A011

HHS Employee

SAC4714A012

Community Based Organization/Non Profit

SAC4714A013

Advocacy Group

SAC4714A014

Journalist/Media

SAC4714A015

Researcher

SAC4714A016

Educator

SAC4714A017

Other, please specify

A

SAC4715

A

What best describe your role in visiting the site today?

Radio button, one-up vertical

Single

Y

Skip Logic Group

OE_Primary Role

SAC4716

Please select your primary reason for visiting the site today? (Please select all that apply).

SAC4716A001

Information on Civil Rights

A

Checkbox, one-up vertical

Multi

Y

Skip Logic Group

Primary Reason

SAC4716A002

Information on Health Information Privacy

B

SAC4716A003

File a Complaint

C,D

SAC4716A004

Information on how to file a Complaint

D

SAC4716A005

Press Releases/News

SAC4716A006

Training Materials

E

SAC4716A007

Just Browsing

SAC4716A008

Sign up for Listserv

SAC4716A009

Other, please specify

Z

SAC4717

Z

Please describe your primary reason for visiting the site today.

Text area, no char limit

N

Skip Logic Group

OE_Primary Reason

SAC4718

A

Please tell us what Civil Rights Information you were looking for today?

SAC4718A001

General Civil Rights Information

Checkbox, one-up vertical

Multi

Y

Skip Logic Group

Civil Rights Info

SAC4718A002

Race, Color and National Origin Discrimination

SAC4718A003

Language Access/L.E.P

SAC4718A004

Disability Discrimination

SAC4718A005

Olmstead

SAC4718A006

Age Discrimination

SAC4718A007

Enforcement Activities

SAC4718A008

Hill-Burton Act

SAC4718A009

Section 1553 of the Affordable Care Act

SAC4718A010

Medicare Part A Certification

SAC4718A011

Federal Health Care Conscience Protection Statues

SAC4718A012

Civil Rights Fact Sheet

SAC4718A013

Other, please specify

AA

SAC4719

AA

Please tell us specifically what Civil Rights Information you were looking for today.

Text area, no char limit

N

Skip Logic Group

OE_Other Civil Rights Info

SAC4720

B

Please tell us what Health Information Privacy Information you were looking for today?

SAC4720A001

General Health Information Privacy Information

Checkbox, one-up vertical

Multi

Y

Skip Logic Group

Health Information

SAC4720A002

HIPAA Privacy Rule

SAC4720A003

HIPAA Security Rule

SAC4720A004

Breach Notification Rule

SAC4720A005

Patient Safety and Quality Improvement Act of 2005 (PSQIA)

SAC4720A006

Audit Program Information

SAC4720A007

Information for Covered Entities

SAC4720A008

Information for Consumers/Individuals

SAC4720A009

States Attorneys General

SAC4720A010

Enforcement Activities

SAC4720A011

Other, please specify

BB

SAC4721

BB

Please tell us specifically what Health Information Privacy Information you were looking for today.

Text area, no char limit

N

Skip Logic Group

OE_Other Health Info

SAC4722

C

Please tell us what type of complaint you were looking to file

SAC4722A001

Civil Rights Discrimination Complaint

Checkbox, one-up vertical

Multi

Y

Skip Logic Group

Civil Rights Complaint Type Info

SAC4722A002

HIPAA Privacy Rule Complaint

SAC4722A003

HIPAA Security Rule Complaint

SAC4722A004

Patient Safety Confidentiality Complaint (PSQIA)

SAC4722A005

Federal Health Care Conscience Protection Statutes

SAC4722A006

Other, please specify

CC

SAC4723

CC

Please tell us what other civil rights discrimination complaint you were looking to file.

Text area, no char limit

N

Skip Logic Group

OE_Other CR Complaint Info

SAC4724

D

Did you download information on how to file a complaint?

SAC4724A001

Yes

DD

Radio button, one-up vertical

Single

N

Skip Logic Group

Download how to File

SAC4724A002

No

SAC4724A003

I don’t know

SAC4725

DD

Was this information useful?

SAC4725A001

Yes

Radio button, one-up vertical

Single

N

Skip Logic Group

Use of How to file complaint

SAC4725A002

No

SAC4725A003

I don’t know

SAC4726

E

Please tell us what training materials you were looking for.

Text area, no char limit

N

Skip Logic Group

OE_Other CR Complaint Info

SAC4727

Did you find what you were looking for on the site today?

SAC4727A001

Yes

Radio button, one-up vertical

Single

Y

Skip Logic Group

Ability to Find

SAC4727A002

No

A,B

SAC4728

A

Please tell us specifically what you couldn't find on the site today:

Text area, no char limit

Single

N

Skip Logic Group

OE_Ability to Find

SAC4729

B

Please tell us why you were not able to find what you were looking for? (Please select all that apply)

SAC4729A001

I could not access the information on site

Checkbox, one-up vertical

Multi

N

Skip Logic Group

Unable to Find

SAC4729A002

The search results did not appear relevant

SAC4729A003

The links did not take me where I wanted

SAC4729A004

The labeling on lists didn't match what I was looking for

SAC4729A005

How the information is organized on the site wasn't clear

SAC4729A006

The navigation options were difficult to understand

SAC4729A007

Other

SAC4730

How did you look for information on the site today? (Please select all that apply.)

SAC4730A001

Search feature at top of page

A

Checkbox, one-up vertical

Multi

Y

Skip Logic Group

Navigation Tools

SAC4730A002

Navigation tabs across the top of the page

C

SAC4730A003

Navigation links along left side of page

C

SAC4730A004

The links along the right side of the page

C

SAC4730A005

The links in the body of the page

C

SAC4730A006

Other, please specify

D

SAC4731

D

Other way I looked for information:

Text area, no char limit

N

Skip Logic Group

OE_Navigation

SAC4732

A

Please tell us about your experience with the site's search feature today. (Please select all that apply.)

SAC4732A001

Results were satisfactory (met my expectations)

Checkbox, one-up vertical

Multi

Y

Skip Logic Group

Search Experience

SAC4732A002

Results were not relevant

SAC4732A003

Too many results

SAC4732A004

Not enough results

SAC4732A005

Returned NO results

SAC4732A006

Received error message(s)

SAC4732A007

Search speed was too slow

SAC4732A008

I experienced a different search issue (please explain):

AA, B

SAC4733

AA

Please tell us what your search experience was today.

Text area, no char limit

N

Skip Logic Group

OE_Search

SAC4734

B

How can we make the search feature more useful to you?

Text area, no char limit

N

Skip Logic Group

OE_Search Improvement

SAC4735

C

What specific ways can we improve your experience navigating this site?

Text area, no char limit

N

OE_Improve Navigation

SAC4736

Do you use social media regularly (at least once a month)?

SAC4736A001

Yes

A,B

Radio button, one-up vertical

Single

N

Skip Logic Group

Social Media Use

SAC4736A002

No

SAC4737

A

Which of the following social media do you use regularly (at least once a month)? (please select all that apply).

SAC4737A001

Facebook

Skip Logic Group

SM_UseRegularly

SAC4737A002

Twitter

SAC4737A003

LinkedIn

SAC4737A004

Blogs

SAC4737A005

YouTube

SAC4737A006

Other, please specify

AA

SAC4738

AA

Other social media used regularly:

Text area, no char limit

N

Skip Logic Group

OE_Other SM

SAC4739

B

How would you like to use social media to interact with this site? (please select all that apply)

SAC4739A001

Bookmark or tag pages

Checkbox, two-up vertical

Multi

N

Skip Logic Group

SM_Interact

SAC4739A002

In social networks

SAC4739A003

By adding comments, ratings, or reviews

SAC4739A004

Reading blogs

SAC4739A005

Receiving newsletters/email updates

SAC4739A006

Subscribing to RSS feeds

SAC4739A007

Audio/video podcasts

SAC4739A008

Adding a widget or gadget to my personalized page

SAC4739A009

Following a microblog (Twitter, Facebook, etc)

SAC4739A010

I'd prefer not to interact with this site through social media

SAC4739A011

Other, please specify

BB

SAC4740

BB

Please tell us another way you would like to use social media to interact with us:

Text area, no char limit

N

Skip Logic Group

OE_SM

SAC4741

Please select the category that includes your age.

SAC4741A001

Under 18

Drop down, select one

Single

N

Age

SAC4741A002

18-24

SAC4741A003

25-34

SAC4741A004

35-44

SAC4741A005

45-54

SAC4741A006

55-64

SAC4741A007

65-74

SAC4741A008

75 or older

SAC4741A009

Prefer not to answer

SAC4742

What is your gender?

SAC4742A001

Male

Drop down, select one

Single

N

Gender

SAC4742A002

Female

SAC4742A003

Prefer not to answer

SAC4743

If you could recommend one change to improve this site what would it be?

Text area, no char limit

N

OE_Improvement