Form #5 Form #5 Feedback Questionnaire for Patients Visiting the Mobile

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

(Attachment G)

Feedback Questionnaire for Patients Visiting the Mobile Web Site

A subset of the questions below will be included in each questionnaire to be administered through the mobile Web site.

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

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

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

4. How would you rate the layout and organization of this mobile site? [insert 5-point rating scale]

5. Were you able to find the information that you were looking for? [yes/no]

6. How easy/difficult was it to find what you were looking for? [insert 5-point rating scale]

7. How easy/difficult was it to read the guide on your cell phone? [insert 5-point rating scale]

8. If you experienced any difficulties in accessing the guide on [topic] through your cell phone, please explain:

9. Did you search for any additional information or guides while you were on the site? [yes/no/don’t remember]

10. Did you sign up for email updates? [yes/no/don’t remember]

11. Overall, how satisfied were you with this mobile Web site? [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.