Survey

Form Approved

OMB No: 09201026

Exp. Date: 07/31/2017

NOTE TO REVIEWER: Instructions for survey skip patterns appear in brackets [ ] in bold text. These instructions will be programmed into the survey tool – respondents will not see these instructions.

Thank you for agreeing to participate in this survey. The purpose of this survey is to help us evaluate and improve [PROGRAM NAME]. Your participation is voluntary. Your identity will not be linked to your survey responses and your responses will be kept confidential. You may skip any question that you do not want to answer.

1. How did you find out about [PROGRAM NAME]? (check all that apply)

   1. Healthcare provider told me about it

   2. Print material (e.g., posters, newspaper)

   3. Social Media (e.g., Facebook, Twitter)

   4. Friend

   5. Other (please specify)

2. How did you register for [PROGRAM NAME]?

   1. I filled out a paper form and my healthcare provider used it to register me

   2. I registered myself online

3. The following questions are about your experience registering for [PROGRAM NAME]. Please answer each question based on how strongly you agree with the statement.

	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
3a. The registration process was easy to complete
3b. The registration process was fast to complete
3c. The registration process was convenient
3d. Overall, I am satisfied with the registration process

4. What is the main reason why you registered for [PROGRAM NAME]?

   1. My healthcare provider recommended that I register

   2. I want to view immunization information for me and my family

   3. I want to print immunization records required by daycare, school or camp

   4. I want to print immunization records required by an employer

   5. Other (please specify)

5. Please complete the following statement: I have used (or plan to use) [PROGRAM NAME] to access immunization records for: (check all that apply)

   1. My child(ren)

   2. Myself

   3. My spouse

   4. My parent(s)

   5. Other (please specify)

6. Which functions of [PROGRAM NAME] have you used? (check all that apply)

   1. Viewed online immunization records

   2. Printed an official immunization certificate

   3. Other (please specify)

   4. Have not yet viewed or printed immunization records since completing the registration process

[If select “b”, go to question 7, if select “a” or “c” but NOT “b”, go to question 8; if select “d” then go to question 11]

7. What was the reason for printing the official immunization certificate? (check all that apply)

   1. My child’s school or day-care required the form

   2. My child’s camp required the form

   3. My employer required the form

   4. I was required to submit the form to obtain a travel visa

   5. I used the form to verify dependents for WIC services

   6. Other (please specify)

8. When viewing the immunization record(s) for yourself or your family member(s), did [PROGRAM NAME] indicate that you or your family member needed a vaccine?

   1. Yes [go to question 9]

   2. No [go to question 10]

9. What action did you take after you learned that a vaccine was needed?

   1. Called my healthcare provider to make sure the vaccine was really needed

   2. Called my healthcare provider to report that the vaccine had already been received and that my record contained an error

   3. Scheduled a visit with my doctor to receive the vaccine

   4. Waiting to discuss it with my healthcare provider

   5. Have not taken any action yet

10. The following questions are about your experience with using [PROGRAM NAME]. Please answer each question based on how strongly you agree with the statement.

	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
10a. When I access [PROGRAM NAME] it is easy to find the information I need
10b. The information included in my (or my family’s) immunization records [PROGRAM NAME] is accurate
10c. It is important to me to have electronic access to my and my family’s immunization records
10d. I would recommend [PROGRAM NAME] to my friends and relatives

[GO TO QUESTION 12]

11. Why have you not accessed [PROGRAM NAME] since completing the registration process? (check all that apply)

    1. I forgot that I had registered for [PROGRAM NAME]

    2. I forgot my login information

    3. I did not need to view immunization records for me or my family

    4. Other (please specify)

Now we would like your feedback on advertising materials that have been used to promote [PROGRAM NAME].

12. Shown here are images of our print materials. Please click on each piece of material that you remember seeing. If you have not seen any of the materials before, please click on the option ‘I haven’t seen any of the materials before’.

1. Images of the print materials

2. I haven’t seen any of the materials before

[NOTE: if answer “b”, end survey]

[NOTE: the following question will be asked for each material that the respondent indicated they had seen before; the selected image will be displayed at the top and the question will appear below it]

13. How helpful was this material in making the decision to register for [PROGRAM NAME]?

    1. Very helpful

    2. Somewhat helpful

    3. Not helpful

Thank you for answering all our questions! Click on the ‘submit’ button to exit the survey.

Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D74, Atlanta, Georgia 30333; ATTN: PRA (09201026)