885 2014 885 Hhs Ocr

American Customer Satisfaction Index (ACSI) E-Government Website Customer Satisfaction Surveys

2014 885 HHS OCR.xlsx

2014 882 CMS Medicare - 2014 891 Treasury Direct v2

OMB: 1090-0008

Document [xlsx]
Download: xlsx | pdf

Overview

Guidelines
Foreign Language Translation
Welcome and Thank You Text
Current Model Qsts
Current CQs
CQs (3-11-13)
CQs (11-29-12)

Sheet 1: Guidelines






















Questionnaire Management Guidelines








































Goals:



















� One consolidated document to track all model and CQ changes throughout the life of the project


















� Questionnaire always matches the live survey


















� Easy and error-free way to submit CQ changes


















� All changes tracked and reflected in one document (DOT will help)







































Questionnaire Resources:








































1
Questionnaire Design and Approval Process














2
Question Grouping Rules















3
OPS vs. Skip Logic Decision for "Other, Please Specify"











4
Model and Custom Question Checks_ SRA













5
Model and Custom Question Checks_ Team LeadManager











6
Model and Custom Question Checks_ DOT













7
Foreign Language Survey Instructions

































Sheet 2: Foreign Language Translation
Client Name:




Measure Name:







Custom Qualifier Page Please Select



Custom Invitation Text? Please Select



Custom Tracker Text? Please Select



Custom Welcome/
Thank You Text?		 Please Select









Language(s) If other language not listed, please specify. Website URL MID(s)
(DOT FILL THIS IN)		 Measure Name(s)
(DOT WIll FILL THIS IN)		 Notes:
Please Select a Language




Please Select a Language




Please Select a Language




Please Select a Language




Please Select a Language




Please Select a Language




Please Select a Language




Please Select a Language




Please Select a Language




Please Select a Language




Please Select a Language




Please Select a Language




Please Select a Language




Please Select a Language




Please Select a Language




Please Select a Language




Please Select a Language




Please Select a Language




Please Select a Language




Please Select a Language




Please Select a Language




Please Select a Language




Please Select a Language




Please Select a Language




Please Select a Language




Please Select a Language




Please Select a Language




Please Select a Language




Please Select a Language




Please Select a Language




Sheet 3: Welcome and Thank You Text
Model Instance Name:








HHS OCR







MID: doQhU1ZZoUowo8IpohgEJg==






Date: 10/10/2011








Welcome and Thank You Text













Directions:










This welcome text is shown at the top of the questionnaire window and the thank you text at the bottom. This is a good place to mention the site/company/agency name so the visitor knows whom they are taking the survey for. Feel free to modify the standard Welcome text shown in the box below.









Examples


Welcome Text Example






















































Welcome Text





















Thank you for visiting our site. You've been randomly chosen to take part in a brief survey to let us know what we're doing well and where we can improve.

Please take a few minutes to share your opinions, which are essential in helping us provide the best online experience possible.






































































































































































































Thank You Text Example


















Thank You Text





















Thank you for taking our survey - and for helping us serve you better.

Please note you will not receive a response from us based on your survey comments. If you would like us to contact you about your feedback, please visit the Contact Us section of our website.

























































































































































































































































































































































































Sheet 4: Current Model Qsts
Model Instance Name:




HHS OCR




MID: doQhU1ZZoUowo8IpohgEJg==


Date: 9/15/2011



Model questions utilize the ACSI methodology to determine scores and impacts

ELEMENTS (drivers of satisfaction)
CUSTOMER SATISFACTION
FUTURE BEHAVIORS







Content (1=Poor, 10=Excellent, Don't Know)
Satisfaction
Return (1=Very Unlikely, 10=Very Likely)

Please rate your perception of the accuracy of information on this site.
What is your overall satisfaction with this site?
(1=Very Dissatisfied, 10=Very Satisfied)
How likely are you to return to this site?

Please rate the quality of information on this site.
How well does this site meet your expectations?
(1=Falls Short, 10=Exceeds)
Recommend (1=Very Unlikely, 10=Very Likely)

Please rate the freshness of content on this site.
How does this site compare to your idea of an ideal website?
(1=Not Very Close, 10=Very Close)
How likely are you to recommend this site to someone else?

Look and Feel (1=Poor, 10=Excellent, Don't Know)


Primary Resource (1=Very Unlikely, 10=Very Likely)

Please rate the visual appeal of this site.


How likely are you to use this site as your primary resource for obtaining information from Health and Human Services Office for Civil Rights?

Please rate the balance of graphics and text on this site.


Trust (1=Strongly Disagree, 10=Strongly Agree)

Please rate the readability of the pages on this site.


I can count on this Agency to act in my best interests.

Navigation (1=Poor, 10=Excellent, Don't Know)


I consider this Agency to be trustworthy.

Please rate how well the site is organized.


This Agency can be trusted to do what is right.

Please rate the options available for navigating this site.




Please rate how well the site layout helps you find what you are looking for.


Please rate the number of clicks to get where you want on this site.

Site Performance (1=Poor, 10=Excellent, Don't Know)

Please rate how quickly pages load on this site.

Please rate the consistency of speed from page to page on this site.




Please rate the ability to load pages without getting error messages on this site.




Online Transparency (1=Poor, 10=Excellent, Don't Know)




Please rate how thoroughly this site discloses information about what this Agency is doing.




Please rate how quickly Agency information is made available on this site.




Please rate how well information about this Agency's actions can be accessed by the public on this site.
























































































Sheet 5: Current CQs
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 Skip Logic Label Question Text AnswerIDs (DOT) Answer Choices
(limited to 50 characters)		 Skip to 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











Student, including research for an assignment










SAC4714A017 Other, please specify A






SAC4715 A What best describes 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










Omnibus HIPAA Rule










SAC4716A003 File a Complaint C,D









SAC4716A004 Information on how to file a Complaint D










HIPAA Audit Protocol










SAC4716A005 Press Releases/News










SAC4716A006 Training Materials E










Research










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)











Model Business Associate Agreement










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

ACQinh0019336
Did you visit the Audit Program Protocol section of the site today?
Yes A,B Radio button, one-up vertical
Y Skip Logic Group Audit Protocol Use





No











Don’t know







ACQinh0019337 A Did you find what you were looking for using the Audit Program Protocol?
Yes
Radio button, one-up vertical
Y Skip Logic Group Audit Protocol Find





No







ACQinh0019338 B Do you have any suggestions for improving the Audit Program Protocol?


Text area, no char limit
N Skip Logic Group OE_Improve Audit Protocol

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







ACQinh0019339
Did you use the one of Frequently Asked Questions portion of the site today?
Yes A,B Radio button, one-up vertical Single Y Skip logic Group FAQ use





No







ACQinh0019340 A Which FAQ section did you use today?
HIPAA











Civil Rights











I don't know/don't remember







ACQinh0019341 B Did you find what you were looking for?
Yes











No BB






ACQinh0019342 BB Please tell us what you could not find using the Frequently Asked questions today:


Text area, no char limit
N Skip Logic Group OE_FAQ Unable to find

ACQinh0023735
How did arrive at this site today?
Search engine (e.g. Google, Bing, etc.)


Y Skip Logic Group Learn about Site





An online ad











Link from another site











Bookmark











Blog or other Social Media (e.g. Facebook, Twitter)











Email Link











Word of mouth











Other (please specify): A






ACQinh0023736 A Please tell us how you learned of this site:


Text area, no char limit
N
OE_Learn about Site

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 B









SAC4732A003 Too many results B









SAC4732A004 Not enough results B









SAC4732A005 Returned NO results B









SAC4732A006 Received error message(s) B









SAC4732A007 Search speed was too slow B









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

ACQinh0023737
Please rate the clarity of the wording on this site.
1=Poor
Radio button, scale, has don't know S Y
Clear





2











3











4











5











6











7











8











9











Excellent=10











Don't know







ACQinh0023738
Please rate how well you understand the wording on this site.
1=Poor
Radio button, scale, has don't know S Y
Understandable





2











3











4











5











6











7











8











9











Excellent=10











Don't know







ACQinh0023739
Please rate the site on its use of short, clear sentences
1=Poor
Radio button, scale, has don't know S Y
Concise





2











3











4











5











6











7











8











9











Excellent=10











Don't know







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

















































































































































































































Sheet 6: CQs (3-11-13)
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 Skip Logic Label Question Text Answer Choices
(limited to 50 characters)		 Skip to Type (select from list) Single or Multi Required
Y/N		 Special Instructions CQ Label

SAC4713
How frequently do you visit this site? This is my first time visiting the site
Radio button, one-up vertical Single Y
Frequency of Visit




Daily










About once a week










About once a month










Every few months










Every 6 months or less often







SAC4714
What best describes your role in visiting the site today? General Public
Radio button, one-up vertical Single Y Skip Logic Group Primary Role




Health Care Professional










Human Services Professional










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










Health Care Clearinghouse










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)










HIPAA Business Associate










Federal Government










State/Local/Tribal Government










Consultant/Legal










HHS Employee










Community Based Organization/Non Profit










Advocacy Group










Journalist/Media










Researcher










Educator










Student, including research for an assignment










Other, please specify A






SAC4715 A What best describes 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). Information on Civil Rights A Checkbox, one-up vertical Multi Y Skip Logic Group Primary Reason




Information on Health Information Privacy B









Omnibus HIPAA Rule










File a Complaint C,D









Information on how to file a Complaint D









HIPAA Audit Protocol










Press Releases/News










Training Materials E









Research










Just Browsing










Sign up for Listserv










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? General Civil Rights Information
Checkbox, one-up vertical Multi Y Skip Logic Group Civil Rights Info




Race, Color and National Origin Discrimination










Language Access/L.E.P










Disability Discrimination










Olmstead










Age Discrimination










Enforcement Activities










Hill-Burton Act










Section 1553 of the Affordable Care Act










Medicare Part A Certification










Federal Health Care Conscience Protection Statues










Civil Rights Fact Sheet










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? General Health Information Privacy Information
Checkbox, one-up vertical Multi Y Skip Logic Group Health Information




HIPAA Privacy Rule










HIPAA Security Rule










Breach Notification Rule










Patient Safety and Quality Improvement Act of 2005 (PSQIA)










Model Business Associate Agreement










Audit Program Information










Information for Covered Entities










Information for Consumers/Individuals










States Attorneys General










Enforcement Activities










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 Civil Rights Discrimination Complaint
Checkbox, one-up vertical Multi Y Skip Logic Group Civil Rights Complaint Type Info




HIPAA Privacy Rule Complaint










HIPAA Security Rule Complaint










Patient Safety Confidentiality Complaint (PSQIA)










Federal Health Care Conscience Protection Statutes










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? Yes DD Radio button, one-up vertical Single N Skip Logic Group Download how to File




No










I don’t know







SAC4725 DD Was this information useful? Yes
Radio button, one-up vertical Single N Skip Logic Group Use of How to file complaint




No










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

ACQinh0019336
Did you visit the Audit Program Protocol section of the site today? Yes A,B Radio button, one-up vertical
Y Skip Logic Group Audit Protocol Use




No










Don’t know







ACQinh0019337 A Did you find what you were looking for using the Audit Program Protocol? Yes
Radio button, one-up vertical
Y Skip Logic Group Audit Protocol Find




No







ACQinh0019338 B Do you have any suggestions for improving the Audit Program Protocol?

Text area, no char limit
N Skip Logic Group OE_Improve Audit Protocol

SAC4727
Did you find what you were looking for on the site today? Yes 
Radio button, one-up vertical Single Y Skip Logic Group Ability to Find




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) I could not access the information on site
Checkbox, one-up vertical Multi N Skip Logic Group Unable to Find




The search results did not appear relevant










The links did not take me where I wanted










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










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










The navigation options were difficult to understand










Other







ACQinh0019339
Did you use the one of Frequently Asked Questions portion of the site today? Yes A,B Radio button, one-up vertical Single Y Skip logic Group FAQ use




No







ACQinh0019340 A Which FAQ section did you use today? HIPAA










Civil Rights










I don't know/don't remember







ACQinh0019341 B Did you find what you were looking for? Yes










No BB






ACQinh0019342 BB Please tell us what you could not find using the Frequently Asked questions today:

Text area, no char limit
N Skip Logic Group OE_FAQ Unable to find



How did arrive at this site today? Search engine (e.g. Google, Bing, etc.)


Y Skip Logic Group Learn about Site




An online ad










Link from another site










Bookmark










Blog or other Social Media (e.g. Facebook, Twitter)










Email Link










Word of mouth


































Other (please specify): A







A Please tell us how you learned of this site:

Text area, no char limit
N
OE_Learn about Site

SAC4730
How did you look for information on the site today? (Please select all that apply.) Search feature at top of page A Checkbox, one-up vertical Multi Y Skip Logic Group Navigation Tools




Navigation tabs across the top of the page C









Navigation links along left side of page C








The links along the right side of the page C









The links in the body of the page C









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.) Results were satisfactory (met my expectations)
Checkbox, one-up vertical Multi Y Skip Logic Group Search Experience




Results were not relevant B









Too many results B









Not enough results B









Returned NO results B









Received error message(s) B









Search speed was too slow B









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



Please rate the clarity of the wording on this site. 1=Poor
Radio button, scale, has don't know S Y
Clear



2








3








4








5








6








7








8








9








Excellent=10








Don't know








Please rate how well you understand the wording on this site. 1=Poor
Radio button, scale, has don't know S Y
Understandable



2








3








4








5








6








7








8








9








Excellent=10








Don't know








Please rate the site on its use of short, clear sentences 1=Poor
Radio button, scale, has don't know S Y
Concise



2








3








4








5








6








7








8








9








Excellent=10








Don't know






SAC4741
Please select the category that includes your age. Under 18
Drop down, select one Single N
Age




18-24










25-34










35-44










45-54










55-64










65-74










75 or older










Prefer not to answer







SAC4742
What is your gender? Male
Drop down, select one Single N
Gender




Female










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

































































































































































































Sheet 7: CQs (11-29-12)
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 Skip Logic Label Question Text Answer Choices
(limited to 50 characters)		 Skip to Type (select from list) Single or Multi Required
Y/N		 Special Instructions CQ Label




SAC4713
How frequently do you visit this site? This is my first time visiting the site
Radio button, one-up vertical Single Y
Frequency of Visit







Daily













About once a week













About once a month













Every few months













Every 6 months or less often










SAC4714
What best describes your role in visiting the site today? General Public
Radio button, one-up vertical Single Y Skip Logic Group Primary Role







Health Care Professional













Human Services Professional













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













Health Care Clearinghouse













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)













HIPAA Business Associate













Federal Government













State/Local/Tribal Government













Consultant/Legal













HHS Employee













Community Based Organization/Non Profit













Advocacy Group













Journalist/Media













Researcher













Educator













Student, including research for an assignment













Other, please specify A









SAC4715 A What best describes 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). Information on Civil Rights A Checkbox, one-up vertical Multi Y Skip Logic Group Primary Reason







Information on Health Information Privacy B












File a Complaint C,D












Information on how to file a Complaint D












HIPAA Audit Protocol













Press Releases/News













Training Materials E












Research













Just Browsing













Sign up for Listserv













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? General Civil Rights Information
Checkbox, one-up vertical Multi Y Skip Logic Group Civil Rights Info







Race, Color and National Origin Discrimination













Language Access/L.E.P













Disability Discrimination













Olmstead













Age Discrimination













Enforcement Activities













Hill-Burton Act













Section 1553 of the Affordable Care Act













Medicare Part A Certification













Federal Health Care Conscience Protection Statues













Civil Rights Fact Sheet













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? General Health Information Privacy Information
Checkbox, one-up vertical Multi Y Skip Logic Group Health Information







HIPAA Privacy Rule













HIPAA Security Rule













Breach Notification Rule













Patient Safety and Quality Improvement Act of 2005 (PSQIA)













Audit Program Information













Information for Covered Entities













Information for Consumers/Individuals













States Attorneys General













Enforcement Activities













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 Civil Rights Discrimination Complaint
Checkbox, one-up vertical Multi Y Skip Logic Group Civil Rights Complaint Type Info







HIPAA Privacy Rule Complaint













HIPAA Security Rule Complaint













Patient Safety Confidentiality Complaint (PSQIA)













Federal Health Care Conscience Protection Statutes













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? Yes DD Radio button, one-up vertical Single N Skip Logic Group Download how to File







No













I don’t know










SAC4725 DD Was this information useful? Yes
Radio button, one-up vertical Single N Skip Logic Group Use of How to file complaint




No








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






Did you visit the Audit Program Protocol section of the site today? Yes A,B Radio button, one-up vertical
Y
Audit Protocol Use







No













Don’t know











A Did you find what you were looking for using the Audit Program Protocol? Yes
Radio button, one-up vertical
Y
Audit Protocol Find







No











B Do you have any suggestions for improving the Audit Program Protocol?

Text area, no char limit
N
OE_Improve Audit Protocol




SAC4727
Did you find what you were looking for on the site today? Yes 
Radio button, one-up vertical Single Y Skip Logic Group Ability to Find







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) I could not access the information on site
Checkbox, one-up vertical Multi N Skip Logic Group Unable to Find







The search results did not appear relevant













The links did not take me where I wanted













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













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













The navigation options were difficult to understand













Other












Did you use the one of Frequently Asked Questions portion of the site today? Yes A,B Radio button, one-up vertical Single Y Skip logic Group FAQ use







No











A Which FAQ section did you use today? HIPAA













Civil Rights













I don't know/don't remember











B Did you find what you were looking for? Yes













No BB










BB Please tell us what you could not find using the Frequently Asked questions today:

Text area, no char limit
N Skip Logic Group OE_FAQ Unable to find




SAC4730
How did you look for information on the site today? (Please select all that apply.) Search feature at top of page A Checkbox, one-up vertical Multi Y Skip Logic Group Navigation Tools







Navigation tabs across the top of the page C












Navigation links along left side of page C











The links along the right side of the page C












The links in the body of the page C












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.) Results were satisfactory (met my expectations)
Checkbox, one-up vertical Multi Y Skip Logic Group Search Experience







Results were not relevant













Too many results













Not enough results













Returned NO results













Received error message(s)













Search speed was too slow













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)? Yes A,B Radio button, one-up vertical Single N Skip Logic Group Social Media Use







No










SAC4737 A Which of the following social media do you use regularly (at least once a month)? (please select all that apply). Facebook



Skip Logic Group SM_UseRegularly







Twitter













LinkedIn













Blogs













YouTube













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) Bookmark or tag pages
Checkbox, two-up vertical Multi N Skip Logic Group SM_Interact







In social networks













By adding comments, ratings, or reviews













Reading blogs













Receiving newsletters/email updates













Subscribing to RSS feeds













Audio/video podcasts













Adding a widget or gadget to my personalized page













Following a microblog (Twitter, Facebook, etc)













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













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. Under 18
Drop down, select one Single N
Age







18-24













25-34













35-44













45-54













55-64













65-74













75 or older













Prefer not to answer










SAC4742
What is your gender? Male
Drop down, select one Single N
Gender







Female













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




















































































































































































































































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