Form 516 CQs for OMB started 3-16-2012

Measures Name/Client name (CQs and Answer choices)
FEMA ReadyGov
EDO11033		Did you find the information you were looking for?	EDO11033A001	Yes		Radio button, one-up vertical	S	Y	Skip Logic Group	Found Information
			EDO11033A002	Partially	B
			EDO11033A003	Still looking	B
			EDO11033A004	No (please specify what you were looking for)	A,B
EDO11034	A	Please specify what you were looking for.				Text area, no char limit		N	Skip Logic Group	Information Seeking
	B	If you did not find your information, what will you do next?				Text area, no char limit		N	Skip Logic Group	Next Steps to Find Info
		Please describe your navigation experience.		I had no difficulty browsing on this site.		Checkbox, one-up vertical	M	Y	Skip Logic Group	Navigation Experience
				Could not navigate back to previous information
				Would often feel lost, not know where I was
				Links did not take me where I expected
				Links/labels are difficult to understand
				Too many links or navigational choices
				Had technical difficulties (e.g. broken link)
				Other, please specify:	A
	A	What other experience did you have with navigation?				Text area, no char limit		N	Skip Logic Group	Other Navigation Experience
		If you used the search/text box feature of the site today to find your information, what was your experience with the search functionality?		Search results were not helpful		Checkbox, one-up vertical	M	Y	Skip Logic Group	Search Experience
				Returned too many results
				Returned not enough results
				Returned no results
				Returned results that were too similar/redundant
				Results were not relevant to my search
				I did not use the search feature today
				Other, please specify:	A
	A	What other experience did you have with the serach fearure?				Text area, no char limit		N	Skip Logic Group	Other Search Experience
		Have you been through a disaster before?		Yes		Radio button, one-up vertical	S	Y		Disaster Survivor
				No
EDO11023		How did you hear about the site? (Please select all that apply)	EDO11023A001	TV Advertising		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	Heard About
			EDO11023A002	Print Advertising
			EDO11023A003	Outdoor Advertising					Randomize
			EDO11023A004	Radio Advertising
			EDO11023A005	Advertising on Social Networks (Facebook, Twiiter)
			EDO11023A006	Internet Advertising
				Employer
				Search Engine
				I Already knew about the site
			EDO11023A007	Other, please specify:	A				Anchor Answer Choice
EDO11024	A	What other sources brought you to the site?				Text area, no char limit		N	Skip Logic Group	Other Heard About Source
VA eBenefits
CWS01722		Did you accomplish what you wanted to on the site?		Yes	A				Skip Logic Group
				I wasn’t planning to accomplish anything in particular
				No, I wanted to:	B, C	Radio button, one-up vertical	Single	Y
CWS01723	A	No, I wanted to:				Text area, no char limit	Single	N	Skip Logic Group
	A	What primary task did you accomplish today?		I checked my claim status for compensation or pension		Radio button, one-up vertical	Single	Y	Skip Logic Group	Acc-Primary Task
				I checked my education claim status
				I registered for eBenefits
				I changed my profile or direct deposit information
				I looked for employment support
				Other (please specify)	A-1
	A-1	What other task did you primarily accomplish?				Text area, no char limit		N	Skip Logic Group	OE_Acc-Primary Task
	B	What primary task were you unable to accomplish today?		Register or Login	B-1	Radio button, one-up vertical	Single	Y	Skip Logic Group	Not Acc-Primary Task
				Check claim status for compensation or pension	B-2
				Check education claim status	B-3
				Apply for a benefit	B-4
				Manage my profile or direct deposit
				Find employment support
				Other, please specify	B-5
	B-1	What difficulty did you have registering or logging into your account?		The site was down		Radio button, one-up vertical				Not Acc-Reg/Login
				My password expired
				I could not register for a Premium (Level 2) Account because I need to get approved in-person
				The information to register that I received in the mail did not work
				Other, please specify	B-1A
	B-1A	What is the other issue you had registering or logging into your account?				Text area, no char limit				OE_Not Acc-Reg/Login
	B-2	What difficulty did you have checking your compensation or pension claim status?		I found my status, but I don't think the data is correct		Radio button, one-up vertical				Not Acc-C/P Claim
				I could not get status because I do not have a Premium (Level 2) account
				I could login, but my page did not display
				Other, please specify	B-2A
	B-2A	What is the other reason that you could not check your claim status?				Text area, no char limit				OE_Not Acc-C/P Claim
	B-3	What difficulty did you have checking your education claim status?		I wanted payment status		Radio button, one-up vertical				Not Acc-Edu. Claim
				I needed certificate of eligibility
				Other, please specify	B-3A
	B-3A	What is the other reason you could not check your education claim status?				Text area, no char limit				OE_Not Acc-Edu. Claim
	B-4	What type of benefit did you try to apply for?				Text area, no char limit				OE_Not Acc-Ben Type
	B-5	What other task were you trying to accomplish?				Text area, no char limit		N	Skip Logic Group	OE_Not Acc-Other Task
ACQOsl0002979	C	What will you do next?	ACQOsl0002979A01	Nothing, although I did not find/complete what I wanted		Radio button, one-up vertical	Single	Y	Skip Logic Group
			ACQOsl0002979A02	Call the eBenefits call center
			ACQOsl0002979A03	Return to the eBenefits site later and try again
			ACQOsl0002979A04	Send an email
			ACQOsl0002979A05	Other (please specify)	C-1
ACQOsl0002980	C-1	What else would you do next?				Text area, no char limit		Y	Skip Logic Group
CDC Jan 2011 - present
ACQOsl0004055		Would you access information from CDC through other electronic channels or devices? (Please select all that apply):	ACQOsl0004055A16	Facebook
			ACQOsl0004055A17	Google+
			ACQOsl0004055A18	LinkedIn
			ACQOsl0004055A19	Twitter
			ACQOsl0004055A03	Mobile websites
			ACQOsl0004055A04	Mobile applications or "apps"
			ACQOsl0004055A05	Text messages
			ACQOsl0004055A06	Online Videos
			ACQOsl0004055A07	Podcasts
			ACQOsl0004055A09	Blogs
			ACQOsl0004055A10	eCards
			ACQOsl0004055A11	Widgets (i.e. module or application you can add to a website or personalized web page like iGoogle or MyYahoo!)
			ACQOsl0004055A12	E-mail updates
			ACQOsl0004055A13	RSS Feeds
				Pinterest
			ACQOsl0004055A14	None of the above
			ACQOsl0004055A15	Other, please specify:
Dod TriWest
CJI0667		Please tell us if you are a beneficiary, provider, or government representative or another type of visitor to our Web site.	CJI0667A001	Beneficiary	A	Radio button, one-up vertical	S	Y	Skip Logic Group	Type of Visitor
			CJI0667A002	Provider/Provider staff	D
			CJI0667A003	Government representative	F
			CJI0667A004	Other	D
CJI0668	A	Please use the dropdown menu below and select the category that best describes your military status.	CJI0668A001	Active Duty	B	Drop down, select one	S	Y		Military Status
			CJI0668A002	Retiree	B
			CJI0668A003	Reserve or Guard	B
			CJI0668A004	Active Duty family member	B
			CJI0668A005	Retiree family member	B
			CJI0668A006	Reserve or Guard family member	B
			CJI0668A007	Other/Not Listed	B
CJI0669	B	What was the primary reason for this visit to TriWest.com?	CJI0669A001	Provider Directory		Radio button, one-up vertical	S	Y		Beneficiary Primary Reason
			CJI0669A002	TRICARE Prime Information
			CJI0669A003	TRICARE Standard or Extra Information
			CJI0669A004	Reserve Component Information
			CJI0669A005	Reviewing Claims
			CJI0669A006	Enrollment
			CJI0669A007	Online Payment
			CJI0669A008	Other/Not Listed	C
CJI0670	C	Please specify the reason for this visit.				Text area, no char limit		N		Beneficiary Other Reason
CJI0671	D	What was the primary reason for this visit to TriWest.com?	CJI0671A001	Referrals and Authorizations (Public Access)		Radio button, one-up vertical	S	Y		Provider Primary Reason
			CJI0671A002	Claims & Reimbursement (Public Access)
			CJI0671A003	TRICARE Policy Updates (Public Access)
			CJI0671A004	Resource Library
			CJI0671A005	Check referral authorization status (Registered Providers)
			CJI0671A006	Submit claims & check claim status online (Registered Providers)
			CJI0671A007	Check patient eligibility (Registered Providers)
			CJI0671A008	Consult tracking reports (Registered Providers)
			CJI0671A009	Other/Not Listed	E
CJI0672	E	Please specify the reason for this visit.				Text area, no char limit		N		Provider Other Reason
CJI0673	F	What was the primary reason for this visit to TriWest.com?	CJI0673A001	MMSO Authorizations & Referrals Work Queue		Radio button, one-up vertical	S	Y		Government Primary Reason
			CJI0673A002	MMSO Claims Work Queue
			CJI0673A003	MTF SHCP Claims Work Queue
			CJI0673A004	HBA/BCAS Claims Data
			CJI0673A005	West Region BSC
			CJI0673A006	West Region Government Reports
			CJI0673A007	JSOPP Reports
			CJI0673A008	West Region Balanced Scorecard (BSC)
			CJI0673A009	TriWest OLAP/BI Reports
			CJI0673A010	Other/Not Listed	G
CJI0674	G	Please specify the reason for this visit.				Text area, no char limit		N		Government Other Reason
CJI0675		How easy was it to find the information you needed on TriWest.com?	CJI0675A001	0=Could Not Find Answer	A	Radio button, one-up vertical	S	Y	Skip Logic Group	Easy to Find Info
			CJI0675A002	1=Very Difficult
			CJI0675A003	2
			CJI0675A004	3
			CJI0675A005	4
			CJI0675A006	5
			CJI0675A007	6
			CJI0675A008	7=Very Easy
			CJI0675A009	Don't Know
CJI0676	A	What information were you looking for that you couldn’t find?				Text area, no char limit		N		Info Not Found
CJI0677		How satisfied are you overall with this Web site?	CJI0677A001	1=Completely Dissatisfied		Radio button, scale, has don't know	S	Y		Site Satisfaction
			CJI0677A002	2
			CJI0677A003	3
			CJI0677A004	4
			CJI0677A005	5
			CJI0677A006	6
			CJI0677A007	7=Completely Satisfied
			CJI0677A008	Don't Know
CJI0678		How satisfied are you, overall, with the services and support that you receive from TriWest Healthcare Alliance?	CJI0678A001	1=Completely Dissatisfied		Radio button, scale, has don't know	S	Y		Service/Support Satisfaction
			CJI0678A002	2
			CJI0678A003	3
			CJI0678A004	4
			CJI0678A005	5
			CJI0678A006	6
			CJI0678A007	7=Completely Satisfied
			CJI0678A008	Don't Know
CJI0679		Attention! Please do not include any personal or clinical information in the space provided below: Please tell us how we can make TriWest.com better and easier to use.				Text area, no char limit		Y		Site Improvement