Form 0917-0036-002 Generic Clearance for the Collection of Qualitative Feed

Form Approved

OMB Form No. 0917-0036-02

Expiration Date: 5/31/2015

Survey Questions

1. How often do you visit this website?

• This is my first visit.

• Daily

• Weekly

• Monthly

2. Based on today’s visit, how would you rate your website experience overall?

• 1 (Unsatisfied)

• 2

• 3

• 4

• 5 (Very satisfied)

3. Which of the following best describes the main purpose of your visit?

• Browse the site.

• Complete time and attendance sheet.

• Find a form.

• Find a hospital, clinic, or other medical facility.

• Find a report.

• Find data sets.

• Find dental providers in my state.

• Find out about events.

• Find out how to report fraud.

• Find regulations and guidance for health practitioners.

• Find information about eligibility for IHS services.

• Find information about Find contact information.

• Get information about health issues.

• Get information about grants and funding.

• Get information about jobs.

• Get information about standards and policies.

• Get information about the Resource and Patient Management System.

• Learn about opportunities in the health community.

• Learn about prevention and wellness.

• Read the Director’s Blog.

• Read the most recent news.

• Read or download publications.

• Sign up for email updates.

• Other. Please specify _____________________

• None of the above.

4. How did you come here today?

• Federal Register Notice

• Bookmark

• Information Center referral

• Television or radio

• Newspaper or magazine

• Friend or colleague

• Link from another website

• Facebook

• Twitter

• YouTube

• USA.gov

• Search Engine (Google, Yahoo, etc.)

5. Were you able to complete the purpose of your visit?

• Yes

• Somewhat

• No

If No or Somewhat: Please tell us why you were not able to fully complete the purpose of your visit today.

6. How do you prefer to find things (navigate) on the site?

• A-Z Index

• External Search Engine (example: Google, Bing, Yahoo)

• Website Navigation (top and left-side of page)

• Scan the page

• Search box on website

• Other, please specify _______________

• None of the above.

7. Which of the following best describes you?

• Health professional.

• Human Services professional.

• Tribal member.

• IHS Employee.

• HHS Employee.

• Tribal Leader.

• Tribal Health facility employee.

• Urban health facility employee.

• Consultant.

• Non-profit organization.

• Other Federal government employee.

• State/Tribal/Local government employee.

• Teacher.

• Student.

• Journalist

• Member of the general public.

• Other, please specify ___________________

8. I am:

• Male

• Female

• Other

9. I am:

• Less than 18 years old

• 18-24 years old

• 25-34 years old

• 35-49 years old

• 50-64 years old

• 65 years old or older

10. My first language is:

• English

• Spanish

• American Indian/Alaska Native language, please specify:___ ________

• Other, please specify: ______________

11. My level of schooling is:

• I am still in elementary or middle school.

• I am still in high school.

• I did not receive a high school diploma or equivalent degree.

• I have a high school diploma or equivalent degree.

• I attended a professional or vocational school.

• I attended, but did not graduate from college.

• I am a college graduate.

• I have some post graduate education or training.

• I have a professional or graduate degree.

12. I am usually on the Internet, at work, home or school, not including email ___ days a week.

• 1

• 2

• 3

• 4

• 5

• 6

• 7

13. I am usually on the internet, at work, home or school, not including email ___hours a day.

• Less than one

• 1-2 hours

• 3-4 hours

• 5-6 hours

• 7-8 hours

• 9-10 hours

• More than 10 hours.

14. I access the internet from my mobile phone:

• Often

• Sometimes

• Never

• Do not own a mobile phone.

15. What one thing on this website would you most like to change or fix? (Please do not include personally identifiable information here).

Comment box.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0917-0036. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer