Form #4 Form #4 Feedback Questionnaire for Patients Requesting Mailed Gu

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

Attachment F)

Feedback Questionnaire for Patients Requesting Mailed Guides

All items below will be included in the questionnaire that will be mailed, along with an addressed and stamped return envelope.

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

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

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

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

5. Is the guide that you requested on [topic] for you or for someone else?

6. To what extent was the guide easy to read [insert 5-point rating scale]?

7. To what extent was the information in the guide easy to understand [insert 5-point rating scale]?

8. How would you rate the helpfulness of the guide in learning more about [topic] [insert 5-point rating scale]?

9. Did you find the information that you were looking for or expected to find?

10. How are you planning to use the information in the guide?

11. How could the guide be improved?

12. How would you rate the text instructions for requesting a printed copy of the guide [insert 5-point rating scale]?

13. How would you rate the amount of text messages required for requesting a printed copy of the guide [insert 5-point rating scale]?

Public reporting burden for this collection of information is estimated to average 10 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.

14. Do you have any suggestion on ways to improve how these guides are made available to you, or any other suggestions?