Form #3 Form #3 Patient Interview Questions

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Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Attachment E)

Patient Interview Questions

Introduction

Good morning/afternoon, my name is [insert interviewee name] and I represent the Eisenberg Center.

We are in the [insert clinic name] clinic to ask patients with specific health conditions about posters and leaflets displayed in the clinic. Do you or a member of your family have one of the following conditions? [List of conditions will depend on promotional material used in each specific clinic]

Would you like to take part in a short interview? The interview will take approximately 15 minutes of your time.

Assessment questions

1. Did you notice a poster/leaflet on [insert topic] in [insert promotional material location]?

2. Did you find the poster/leaflet interesting?

   1. (if yes) What (in the poster/leaflets) draw your attention?

3. After seeing the poster/leaflet, did you request information about your/your family member’s condition?

   1. (if yes) Were the instructions on the leaflet/poster easy or difficult to understand?

   2. (if no) What were the main reasons why you did not request information about your condition? (probe: no cell phone, cost, limited coverage, lack of familiarity with texting or web browsing)

4. Is there anything about the posters or the information provided in the posters that could have been improved?

Demographic information

5. Do you have regular access to the Internet on a computer or a mobile phone?

6. What is your race [insert demographic categories]?

Public reporting burden for this collection of information is estimated to average 15 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

7. What is your age group [insert age brackets]?

8. What is the current income of your household [insert income brackets]?