Form 1106 2014 861 VA-My HealtheVet

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Overview

Current Model Qsts
My HealtheVet Current CQs
CQs (8-26-14)
Custom Qsts (3-14-14)
Custom Qsts (3-13-14)
Current Custom Qsts (3-7-14)
Current Custom Qsts (1-22-14)
Current Custom Qsts (1-17-14)
Current Custom Qsts (1-15-14)
Current Custom Qsts (11-8-13)
Current Custom Qsts (9-16-13)
Current Custom Qsts (5-9-13)
Current Custom Qsts (4-9-13)
Custom Qsts (11-16-12)
Custom Qsts (11-1-12)
Current Custom Qsts (5-21-12)
Custom Qsts (3-8-12)
Custom Qsts 4-20-11
Custom Qsts 1-10-11
Custom Qsts 10-22-10
Custom Qsts (7-8-10)
Custom Qsts (2-24-10)
Custom Qsts (11-06-09)
Custom Qsts (09-24-09)
Custom Qsts (8-11-09)
Custom Qsts 06-22-09
Custom Qsts 02-17-09
Custom Qsts (10-20-08)
Custom Qsts (10-17-2008)
Custom Qsts (7-22-2008)

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Sheet 1: Current Model Qsts

Model Instance Name: VA - My HealtheVet
MID:	NJxFtMU9UosBkJZRd48x9Q==
Date:	7/21/2008
MID: MODEL QUESTION LIST
Model questions utilize the ACSI methodology to determine scores and impacts
	ELEMENTS (drivers of satisfaction)		CUSTOMER SATISFACTION		FUTURE BEHAVIORS
	Content (1=Poor, 10=Excellent, Don't Know)		Satisfaction		Likelihood to Return (1=Not Very Likely, 10=Very Likely)
1	Please rate the accuracy of information on this site.	21	What is your overall satisfaction with this site? (1=Very Dissatisfied, 10=Very Satisfied)	24	How likely are you to return to this site?
2	Please rate the quality of information on this site.	22	How well does this site meet your expectations? (1=Falls Short, 10=Exceeds)		Recommend (1=Not Very Likely, 10=Very Likely)
3	Please rate the freshness of content on this site.	23	How does this site compare to your idea of an ideal website? (1=Not Very Close, 10=Very Close)	25	How likely are you to recommend this site to someone else?
	Functionality (1=Poor, 10=Excellent, Don't Know)				Organization Satisfaction (1=Not Very Likely, 10=Very Likely)
4	Please rate the usefulness of the services provided on this site.			26	Considering all of your experiences to date, how satisfied are you with the My HealtheVet program overall?
5	Please rate the convenience of the services on this site.
6	Please rate the ability to accomplish what you wanted to on this site.
	Look and Feel (1=Poor, 10=Excellent, Don't Know)
7	Please rate the ease of reading this site.
8	Please rate the clarity of site organization.
9	Please rate the clean layout of this site.
	Navigation (1=Poor, 10=Excellent, Don't Know)
10	Please rate the degree to which the number of steps to get where you want is acceptable.
11	Please rate the ability to find information you want on this site.
12	Please rate the clarity of site map/directory.
13	Please rate the ease of navigation on this site.
	Site Performance (1=Poor, 10=Excellent, Don't Know)
14	Please rate the speed of loading the page on this site.
15	Please rate the consistency of speed on this site.
16	Please rate the reliability of site performance on this site.
	Search (1=Poor, 10=Excellent, Don't Know)
17	Please rate the usefulness of search results on this site.
18	Please rate how this site provides comprehensive search results.
19	Please rate the organization of search results on this site.
20	Please rate how the search feature helps you to narrow the results to find the information you want.

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Sheet 2: My HealtheVet Current CQs

Model Instance Name: VA - My HealtheVet			red & strike-through: DELETE
MID:	NJxFtMU9UosBkJZRd48x9Q==		underlined & italicized: RE-ORDER
			pink: ADDITION
Date:	3/14/2014		blue + -->: REWORDING
20140110 - MHV Meaningful Use Wave 2 l Custom Questions.xlsx			violet (bold): SKIP-LOGIC	As programmed wave 2 Jan
My HealtheVet CUSTOM QUESTION LIST
QID	Skip Logic Label	Question Text	Answer Choices (limited to 50 characters)	Skip to	Type (select from list)	Single or Multi	Required Y/N	Special Instructions	Question Label
ALM0170		Which of the following best describes you?	Active duty	A, B	Checkbox, one-up vertical	Multi	Y	Skip Logic	ANRole
			National Guard/Reserve	A, B
			Veteran	A, B
			Family member of a Veteran or Servicemember
			Caregiver of a Veteran or Servicemember (other than family)
			Veteran Service Organization member
			VA employee
			Non-VA federal government employee
			State/local government employee
			General public
			Other role
CAS0028943	A	Do you get care at a VA facility?	Yes		Drop down, select one	Single	Y	Skip Logic	ANFacilCare
			No
			Not Sure
JIC00178	B	In general, how would you rate your overall health?	Excellent		Drop down, select one	Single	Y	Skip Logic	ANHealth
			Very Good
			Good
			Fair
			Poor
RJB00026		Andrea Fuhrel-Forbis: DOT - please add a space between "My" and "HealtheVet" as I've done here Are you a registered user on the My HealtheVet web site?	Yes	A, B	Drop down, select one	Single	Y	Skip Logic	ANRegUser
			No
			Not sure
CAS0028940	A	Your member log-in box now includes an icon for your account type. What type of My HealtheVet account do you have?	Basic (B)		Drop down, select one	Single	Y	Skip Logic	ANUserType
			Advanced (A)
			Premium (authenticated or IPA’d)(P)
			Not sure
HAR0063550	B	Did you try to log in to the My HealtheVet site today?	Yes	C	Drop down, select one	Single	N	Skip Logic	Log Into Site
			No
HAR0063551	C	Were you able to log in successfully?	Yes, the first time I tried		Drop down, select one	Single	N	Skip Logic	Log In Successfully
			Yes, after more than one try	D
			No, I was unable to log in	D
HAR0063552	D	Please tell us more about your experience logging in.	My login information wasn't recognized/site would not accept my login information		Checkbox, one-up vertical	Multi	N	Skip Logic	Log In Experience
			I was unable to register
			I forgot my username and was unable to retrieve it (e.g., retrieval process did not work, I was not aware there was a retrieval process)
			I forgot my password and was unable to retrieve it (e.g., retrieval process did not work, I was not aware there was a retrieval process)
			Account was locked
			The answer to my security question was not accepted
			I received a site maintenance/error message
			After logging in, information was unavailable
			Website wasn't responding
			Other issue logging in
ALM0169		How frequently do you visit the My HealtheVet web site?	First time		Dropdown (Select-one)	Single	Y		ANMHVFreq
			Daily or more than once a day
			About once a week
			About once a month
			About every 6 months
			Less than every 6 months
			Not sure/Do not recall
HAR0063553		Of the things you tried to do on the site today, what were you able to do? (Please select all that apply)	Learn more about features that are available		Checkbox, one-up vertical	Multi	N		Accomplished
			Request a prescription refill
			View my medication history
			Use Secure Messaging to communicate with my VA health care team
			Use the Blue Button (Download My Data)
			View my VA Appointments
			Look up information about a health condition or medication
			View my lab or other test results
			View my VA Wellness Reminders
			View my VA Notes (written by my health care team)
			Enter my personal information (emergency contacts, etc.)
			Enter data that I track myself such as weight, blood pressure, blood sugar, etc.
			Enter information about my non-VA medications or supplements
			Find a VA facility
			Find information about VA Health Benefits
			Find information about VA Benefits other than health benefits
			Use the Veterans Health Library
			Complete a HealtheLiving Assessment
			Other
HAR0063554		Of the things you tried to do on the site today, what were you NOT able to do? (Please select all that apply)	Learn more about features that are available		Checkbox, one-up vertical	Multi	N		NotAccomplished
			Request a prescription refill
			View my medication history
			Use Secure Messaging to communicate with my VA health care team
			Use the Blue Button (Download My Data)
			View my VA Appointments
			Look up information about a health condition or medication
			View my lab or other test results
			View my VA Wellness Reminders
			View my VA Notes (written by my health care team)
			Enter my personal information (emergency contacts, etc.)
			Enter data that I track myself such as weight, blood pressure, blood sugar, etc.
			Enter information about my non-VA medications or supplements
			Find a VA facility
			Find information about VA Health Benefits
			Find information about VA Benefits other than health benefits
			Use the Veterans Health Library
			Complete a HealtheLiving Assessment
			Other
HAR0063555		Did you use the site's search feature today?	Yes	A	Radio button, one-up	Single	Y	Skip Logic Group	UsedSearch
			No
			Not sure/Do Not Recall
HAR0063556	A	Please tell us about your experience with the site's search feature today. (Please select all that apply)	Search results were helpful		Checkbox, one-up vertical	Multi	Y	Mutually Exclusive	SearchExperience
			Results were not relevant/not what I wanted
			Too many results/I needed to refine my search					Skip Logic Group
			Not enough results
			Returned NO results
			Received error message(s)
			Search speed was too slow
			I had a different search issue
HAR0050203		How would you describe your navigation experience on My HealtheVet today? (Please select all that apply)	I had no difficulty navigating/browsing on this site		Checkbox, one-up vertical	Multi	Y	Mutually Exclusive	NavExperience
			Links often did not take me where I expected					Skip Logic Group
			Had difficulty finding relevant information
			Links/labels are difficult to understand
			Too many links/navigational options to choose from
			Had technical difficulties (error messages, broken links, etc.)	A
			Could not navigate back to previous information
			I had a navigation difficulty not listed above
HAR0063508	A	What was the main type of technical difficulty you experienced today?	Page "updating"	B	Radio Button, one-up	Single	N	Skip Logic Group	TechDifficultiesSingle
			Page did not load completely	B
			Received an error message	B, C
			Clicked on links that were broken	B
			Page too slow to load	B
			Data refresh did not complete	B
			My session timed out	B
			Other technical difficulty not listed above	B
			Do not recall
HAR0063509	B	On which page or feature did you experience the technical difficulty?	Home page		Radio Button, one-up	Single	N	Skip Logic Group	TechDiffPagesSingle
			Registering for an account
			Logging into my account
			Rx Refill
			Health calendar
			VA Blue Button
			VA CCD
			Veterans Health Library
			VA Appointments
			Secure Messaging
			Track health
			Other /Do not recall
HAR0063510	C	Please tell us more about the type of error message(s) you received.	The requested file/page was not found (Error 404)		Checkbox, one-up vertical	Multi	N	Skip Logic Group	TechDiffErrorsSingle
			Server busy (Error 500)
			Request cannot be processed at this time
			Information is not available
			You are not authorized to view the information you requested
			Other
CAS0046943		How long have you been using My HealtheVet?	Less than 6 months		Radio button, one-up vertical	Single	Y		PRYrsUse
			6 months - less than 1 year
			1-2 years
			More than 2 years
			Not sure/Do Not Recall
RJB00029		My use of the My HealtheVet personal health record has improved my ability to manage my health.	Strongly disagree		Radio button, one-up vertical	Single	Y		MHV improve Health
			Disagree
			Not sure
			Disagree
			Agree
			Strongly agree
			Not applicable
CAS0029040		What additional services would you like to see on My HealtheVet? (Please select your top 3 choices)	Schedule or change my VA appointments		Checkbox, one-up vertical	Multi	N	Select up to 3	Additional Services
			Track the status of my prescription refill delivery
			View/pay my VA bills/copayments
			View a list of my VA health care providers and their contact information
			Use a mobile app for My HealtheVet
			Join an online forum to discuss health issues with other Veterans
			Advance check-in for my VA clinic visits
			Authorize sharing information I have stored in My HealtheVet with other people (e.g., family, caregiver)
			Authorize sharing information that I have stored in My HealtheVet with my VA health care team
			Authorize sharing information that I have stored in My HealtheVet with my Non-VA health care provider
			Check to determine if my different medications are safe when taken together
			More online educational programs
			Receive a monthly email newsletter
			Receive notification of new content/features on the site
			Other
ALM0173		What is the main improvement that you would suggest for the My HealtheVet web site?			Text area, no char limit		N		ENDRequest
AED06379		Other than right now, have you completed this survey within the past 3 months?	Yes		Radio button, one-up vertical	Single	N		Survey
			No
			Don't recall
RJB00048		Please indicate your military period(s) of service:	Global War on Terror (OEF/OIF/OND)		Checkbox, one-up vertical	Multi	N		ANMilServ
			Desert Shield/Desert Storm
			Vietnam War
			Korean War
			World War II
			Peacetime Service
			Other
		Mutually exclusive	Not Applicable
AED02714		What is your age range?	Under 20		Dropdown (Select-one)	Single	N		ANAge
			20-24
			25-29
			30-34
			35-39
			40-44
			45-49
			50-54
			55-59
			60-64
			65-69
			70-74
			75-79
			80-84
			85 or older
JIC00267		What is your gender?	Male		Dropdown (Select-one)	Single	N		ANGender
			Female
CAS0028939		Which of the following best describes the highest level of education you have completed?	Did not complete high school		Radio button, one-up vertical	Single	Y		ANEduc
			High school graduate
			Some college or vocational school
			College graduate
			Some postgraduate school
			Graduate or professional degree

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Sheet 3: CQs (8-26-14)

Model Instance Name: VA - My HealtheVet			red & strike-through: DELETE
MID:	NJxFtMU9UosBkJZRd48x9Q==		underlined & italicized: RE-ORDER
			pink: ADDITION
Date:	3/14/2014		blue + -->: REWORDING
20140110 - MHV Meaningful Use Wave 2 l Custom Questions.xlsx			violet (bold): SKIP-LOGIC	As programmed wave 2 Jan
My HealtheVet CUSTOM QUESTION LIST
QID	Skip Logic Label	Question Text	Answer Choices (limited to 50 characters)	Skip to	Type (select from list)	Single or Multi	Required Y/N	Special Instructions	Question Label
ALM0170		Which of the following best describes you?	Active duty	A, B	Checkbox, one-up vertical	Multi	Y	Skip Logic	ANRole
			National Guard/Reserve	A, B
			Veteran	A, B
			Family member of a Veteran or Servicemember
			Caregiver of a Veteran or Servicemember (other than family)
			Veteran Service Organization member
			VA employee
			Non-VA federal government employee
			State/local government employee
			General public
			Other role
CAS0028943	A	Do you get care at a VA facility?	Yes		Drop down, select one	Single	Y	Skip Logic	ANFacilCare
			No
			Not Sure
JIC00178	B	In general, how would you rate your overall health?	Excellent		Drop down, select one	Single	Y	Skip Logic	ANHealth
			Very Good
			Good
			Fair
			Poor
RJB00026		Andrea Fuhrel-Forbis: DOT - please add a space between "My" and "HealtheVet" as I've done here Are you a registered user on the My HealtheVet web site?	Yes	A, B	Drop down, select one	Single	Y	Skip Logic	ANRegUser
			No
			Not sure
CAS0028940	A	Your member log-in box now includes an icon for your account type. What type of My HealtheVet account do you have?	Basic (B)		Drop down, select one	Single	Y	Skip Logic	ANUserType
			Advanced (A)
			Premium (authenticated or IPA’d)(P)
			Not sure
	B	Did you try to log in to the My HealtheVet site today?	Yes	C	Drop down, select one	Single	N	Skip Logic	Log Into Site
			No
	C	Were you able to log in successfully?	Yes, the first time I tried		Drop down, select one	Single	N	Skip Logic	Log In Successfully
			Yes, after more than one try	D
			No, I was unable to log in	D
	D	Please tell us more about your experience logging in.	My login information wasn't recognized/site would not accept my login information		Checkbox, one-up vertical	Multi	N	Skip Logic	Log In Experience
			I was unable to register
			I forgot my username and was unable to retrieve it (e.g., retrieval process did not work, I was not aware there was a retrieval process)
			I forgot my password and was unable to retrieve it (e.g., retrieval process did not work, I was not aware there was a retrieval process)
			Account was locked
			The answer to my security question was not accepted
			I received a site maintenance/error message
			After logging in, information was unavailable
			Website wasn't responding
			Other issue logging in
ALM0169		How frequently do you visit the My HealtheVet web site?	First time		Dropdown (Select-one)	Single	Y		ANMHVFreq
			Daily or more than once a day
			About once a week
			About once a month
			About every 6 months
			Less than every 6 months
			Not sure/Do not recall
RJB00022		What were you trying to accomplish today in My HealtheVet? (Please select all that apply)	Learn more about features that are available		Checkbox, one-up vertical	Multi	Y		ANReason
			Request a prescription refill
			View my medication history
			Use Secure Messaging to communicate with my VA health care team
			Use the Blue Button (Download My Data)
			View my VA Appointments
			Look up information about a health condition or medication
			View my lab or other test results
			View my VA Wellness Reminders
			View my VA Notes (written by my health care team)
			Enter my personal information (emergency contacts, etc.)
			Enter data that I track myself such as weight, blood pressure, blood sugar, etc.
			Enter information about my non-VA medications or supplements
			Find a VA facility
			Find information about VA Health Benefits
			Find information about VA Benefits other than health benefits
			Use the Veterans Health Library
			Complete a HealtheLiving Assessment
			Other
ALM0172		Did you accomplish what you wanted to in My HealtheVet?	Yes		Dropdown (Select-one)	Single	Y	Skip Logic Group	ANTaskAcc
			No
			Partially
			Not finished yet
		Of the things you tried to do on the site today, what were you able to do? (Please select all that apply)	Learn more about features that are available			Multi	N	Skip Logic Group	Accomplished
			Request a prescription refill
			View my medication history
			Use Secure Messaging to communicate with my VA health care team
			Use the Blue Button (Download My Data)
			View my VA Appointments
			Look up information about a health condition or medication
			View my lab or other test results
			View my VA Wellness Reminders
			View my VA Notes (written by my health care team)
			Enter my personal information (emergency contacts, etc.)
			Enter data that I track myself such as weight, blood pressure, blood sugar, etc.
			Enter information about my non-VA medications or supplements
			Find a VA facility
			Find information about VA Health Benefits
			Find information about VA Benefits other than health benefits
			Use the Veterans Health Library
			Complete a HealtheLiving Assessment
			Other
		Of the things you tried to do on the site today, what were you NOT able to do? (Please select all that apply)	Learn more about features that are available			Multi	N	Skip Logic Group	NotAccomplished
			Request a prescription refill
			View my medication history
			Use Secure Messaging to communicate with my VA health care team
			Use the Blue Button (Download My Data)
			View my VA Appointments
			Look up information about a health condition or medication
			View my lab or other test results
			View my VA Wellness Reminders
			View my VA Notes (written by my health care team)
			Enter my personal information (emergency contacts, etc.)
			Enter data that I track myself such as weight, blood pressure, blood sugar, etc.
			Enter information about my non-VA medications or supplements
			Find a VA facility
			Find information about VA Health Benefits
			Find information about VA Benefits other than health benefits
			Use the Veterans Health Library
			Complete a HealtheLiving Assessment
			Other
HAR0050202		How did you primarily look for information on/navigate the site today?	Search feature	A	Radio button, one-up	Single	Y	Skip Logic Group	NavMethods
			Top navigation bar
			Links elsewhere on the page
			Quick links
			Used FAQs tab
			Used Learn More tab
			Set a bookmark in my browser to a specific page on the site
			Contacted the Help Desk
			Other /Do not recall
		Did you use the site's search feature today?	Yes	A	Radio button, one-up	Single	Y	Skip Logic Group	UsedSearch
			No
			Not sure/Do Not Recall
	A	Please tell us about your experience with the site's search feature today. (Please select all that apply)	Search results were helpful		Checkbox, one-up vertical	Multi	Y	Mutually Exclusive	SearchExperience
			Results were not relevant/not what I wanted
			Too many results/I needed to refine my search					Skip Logic Group
			Not enough results
			Returned NO results
			Received error message(s)
			Search speed was too slow
			I had a different search issue
HAR0050203		How would you describe your navigation experience on My HealtheVet today? (Please select all that apply)	I had no difficulty navigating/browsing on this site		Checkbox, one-up vertical	Multi	Y	Mutually Exclusive	NavExperience
			Links often did not take me where I expected					Skip Logic Group
			Had difficulty finding relevant information
			Links/labels are difficult to understand
			Too many links/navigational options to choose from
			Had technical difficulties (error messages, broken links, etc.)	A
			Could not navigate back to previous information
			I had a navigation difficulty not listed above
	A	What was the main type of technical difficulty you experienced today?	Page "updating"	B	Radio Button, one-up	Single	N	Skip Logic Group	TechDifficultiesSingle
			Page did not load completely	B
			Received an error message	B, C
			Clicked on links that were broken	B
			Page too slow to load	B
			Data refresh did not complete	B
			My session timed out	B
			Other technical difficulty not listed above	B
			Do not recall
HAR0050205	B	On which page(s) or feature(s) did you experience the technical difficulty? (Please select all that apply)	Home page		Checkbox, one-up vertical	Multi	N	Skip Logic Group	TechDiffPages
			Registering for an account
			Logging into my account
			Rx Refill
			Health calendar
			VA Blue Button
			VA CCD
			Veterans Health Library
			VA Appointments
			Secure Messaging
			Track health
			Other /Do not recall
	B	On which page or feature did you experience the technical difficulty?	Home page		Radio button	Single	N	Skip Logic Group	TechDiffPagesSingle
			Registering for an account
			Logging into my account
			Rx Refill
			Health calendar
			VA Blue Button
			VA CCD
			Veterans Health Library
			VA Appointments
			Secure Messaging
			Track health
			Other /Do not recall
	C	Please tell us more about the type of error message(s) you received.	The requested file/page was not found (Error 404)		Checkbox, one-up vertical	Multi	N	Skip Logic Group	TechDiffErrors
			Server busy (Error 500)
			Request cannot be processed at this time
			Information is not available
			You are not authorized to view the information you requested
			Other
CAS0046943		How long have you been using My HealtheVet?	Less than 6 months		Radio button, one-up vertical	Single	Y		PRYrsUse
			6 months - less than 1 year
			1-2 years
			More than 2 years
			Not sure/Do Not Recall
RJB00029		My use of the My HealtheVet personal health record has improved my ability to manage my health.	Strongly disagree		Radio button, one-up vertical	Single	Y		MHV improve Health
			Disagree
			Not sure
			Disagree
			Agree
			Strongly agree
			Not applicable
CAS0029040		What additional services would you like to see on My HealtheVet? (Please select your top 3 choices)	Schedule or change my VA appointments		Checkbox, one-up vertical	Multi	N	Select up to 3	Additional Services
			Track the status of my prescription refill delivery
			View/pay my VA bills/copayments
			View a list of my VA health care providers and their contact information
			Use a mobile app for My HealtheVet
			Join an online forum to discuss health issues with other Veterans
			Advance check-in for my VA clinic visits
			Authorize sharing information I have stored in My HealtheVet with other people (e.g., family, caregiver)
			Authorize sharing information that I have stored in My HealtheVet with my VA health care team
			Authorize sharing information that I have stored in My HealtheVet with my Non-VA health care provider
			Check to determine if my different medications are safe when taken together
			More online educational programs
			Receive a monthly email newsletter
			Receive notification of new content/features on the site
			Other
ALM0173		What is the main improvement that you would suggest for the My HealtheVet web site?			Text area, no char limit		N		ENDRequest
AED06379		Other than right now, hHave you completed this survey within the past 3 months?	Yes		Radio button, one-up vertical	Single	N		Survey
			No
			Don't recall
RJB00048		Please indicate your military period(s) of service:	Global War on Terror (OEF/OIF/OND)		Checkbox, one-up vertical	Multi	N		ANMilServ
			Desert Shield/Desert Storm
			Vietnam War
			Korean War
			World War II
			Peacetime Service
			Other
		Mutually exclusive	Not Applicable
AED02714		What is your age range?	Under 20		Dropdown (Select-one)	Single	N		ANAge
			20-24
			25-29
			30-34
			35-39
			40-44
			45-49
			50-54
			55-59
			60-64
			65-69
			70-74
			75-79
			80-84
			85 or older
JIC00267		What is your gender?	Male		Dropdown (Select-one)	Single	N		ANGender
			Female
CAS0028939		Which of the following best describes the highest level of education you have completed?	Did not complete high school		Radio button, one-up vertical	Single	Y		ANEduc
			High school graduate
			Some college or vocational school
			College graduate
			Some postgraduate school
			Graduate or professional degree

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Sheet 4: Custom Qsts (3-14-14)

Model Instance Name: VA - My HealtheVet				red & strike-through: DELETE
MID:	NJxFtMU9UosBkJZRd48x9Q==			underlined & italicized: RE-ORDER
				pink: ADDITION
Date:	6/23/2009			blue + -->: REWORDING
20140110 - MHV Meaningful Use Wave 2 l Custom Questions.xlsx				violet (bold): SKIP-LOGIC	As programmed wave 2 Jan
MID: CUSTOM QUESTION LIST
QID	Skip Logic Label	Question Text	Answer IDs (DOT ONLY)	Answer Choices (limited to 50 characters)	Skip to	Type (select from list)	Single or Multi	Required Y/N	Special Instructions	Question Label
ALM0170		Which of the following best describes you?		Active duty		Checkbox, one-up vertical	Multi	Y		ANRole
				National Guard/Reserve
				Veteran
				Family member of a vVeteran or Servicemember
				Caregiver of a Veteran or Servicemember (other than family)
				Veteran Service Organization member
				VA employee
				Non-VA federal government employee
				State/local government employee
				General public
				Other role
RJB00048		Please indicate your military period(s) of service:		Andrea Fuhrel-Forbis: This top response option is not showing up properly in the test survey - there are not slashes between the OEF/OIF/OND as there should be Global War on Terror (OEF/OIF/OND)		Checkbox, one-up vertical	Multi	N		ANMilServ
				Desert Shield/Desert Storm
				Vietnam War
				Korean War
				World War II
				Peacetime Service
				Other
		Mutually exclusive		Not Applicable
AED02714		What is your age range?		Under 20		Dropdown (Select-one)	Single	N		ANAge
				20-24
				25-29
				30-34
				35-39
				40-44
				45-49
				50-54
				55-59
				60-64
				65-69
				70-74
				75-79
				80-84
				85 or older
JIC00267		What is your gender?		Male		Dropdown (Select-one)	Single	N		ANGender
				Female
CAS0028939		Which of the following best describes the highest level of education you have completed?		Did not complete high school		Radio button, one-up vertical	Single	Y		ANEduc
				High school graduate
				Some college or vocational school
				College graduate
				Some postgraduate school
				Graduate or professional degree
JIC00178		In general, how would you rate your overall health?		Excellent		Drop down, select one	Single	Andrea Fuhrel-Forbis: This is not showing up in survey test as being required Y		ANHealth
				Very Good
				Good
				Fair
				Poor
RJB00026		Are you a registered user on the MyHealtheVet web site?		Yes	A	Drop down, select one	Single	Andrea Fuhrel-Forbis: This is not showing up in survey test as being required Y	Skip Logic	ANRegUser
				No
				Not sure
CAS0028940	A	Your member log-in box now includes an icon for your account type. What type of My HealtheVet account do you have?		Basic (B)		Drop down, select one	Single	Y	Skip Logic	ANUserType
				Advanced (A)
				Premium (authenticated or IPA’d)(P)
				Not sure
ALM0169		How frequently do you visit the My HealtheVet web site?		First time		Dropdown (Select-one)	Single	Andrea Fuhrel-Forbis: This is not showing up in survey test as being required Y		ANMHVFreq
				Daily or more than once a day
				About once a week
				About once a month
				About every 6 months
				Less than every 6 months
				Not sure/Do not recall
RJB00022		What were you trying to accomplish today in My HealtheVet? (Please select all that apply)		Learn more about features that are available		Checkbox, one-up vertical	Multi	Y		ANReason
				Request a prescription refill
				View my medication history
				Use Secure Messaging to communicate with my VA health care team
				Use the Blue Button (Download My Data)
				View my VA Appointments
				Look up information about a health condition or medication
				View my lab or other test results
				View my VA Wellness Reminders
				View my VA Notes (written by my health care team)
				Enter my personal information (emergency contacts, etc.)
				Enter data that I track myself such as weight, blood pressure, blood sugar, etc.
				Enter information about my non-VA medications or supplements
				Find a VA facility
				Find information about VA Health Benefits
				Find information about VA Benefits other than health benefits
				Other
ALM0172		Did you accomplish what you wanted to in My HealtheVet?		Yes		Dropdown (Select-one)	Single	Andrea Fuhrel-Forbis: This is not showing up in survey test as being required Y		ANTaskAcc
				No
				Partially
				Not finished yet
HAR0050202		How did you look for information on/navigate the site today? (Please select all that apply)		Search feature		Checkbox, one-up vertical	Multi	Y		NavMethods
				Top navigation bar
				Links elsewhere on the page
				Quick links
				Used FAQs tab
				Used Learn More tab
				Set a bookmark in my browser to a specific page on the site
				Contacted the Help Desk
				Other /Do not recall
HAR0050203		How would you describe your navigation experience on My HealtheVet today? (Please select all that apply)		I had no difficulty navigating/browsing on this site		Checkbox, one-up vertical	Multi	Y	Mutually Exclusive	NavExperience
				Links often did not take me where I expected					Skip Logic Group
				Had difficulty finding relevant information
				Links/labels are difficult to understand
				Too many links/navigational options to choose from
				Had technical difficulties (error messages, broken links, etc.)	A
				Could not navigate back to previous information
				I had a navigation difficulty not listed above
HAR0050204	A	What type(s) of technical difficulties did you experience today? (Please select all that apply)		Page "updating"	B	Checkbox, one-up vertical	Multi	N	Skip Logic Group	TechDifficulties
				Page did not load completely	B
				Received an error message	B
				Clicked on links that were broken	B
				Page too slow to load	B
				Other technical difficulty not listed above	B
				Do not recall
HAR0050205	B	On which page(s) or feature(s) did you experience the technical difficulty? (Please select all that apply)		Home page		Checkbox, one-up vertical	Multi	N	Skip Logic Group	TechDiffPages
				Registering for an account
				Logging into my account
				Rx Refill
				Health calendar
				VA Blue Button
				VA CCD
				Veterans Health Library
				VA Appointments
				Secure Messaging
				Track health
				Other /Do not recall
CAS0028943		Do you get care at a VA facility?		Yes		Drop down, select one	Single	Y		ANFacilCare
				No
				Not Sure
CAS0046943		How long have you been using My HealtheVet?		Less than 6 months		Radio button, one-up vertical	Single	Y		PRYrsUse
				6 months - less than 1 year
				1-2 years
				More than 2 years
				Not sure/Do Not Recall
RJB00029		My use of the My HealtheVet personal health record has improved my ability to manage my health.		Strongly disagree		Radio button, one-up vertical	Single	Y		MHV improve Health
				Disagree
				Not sure
				Disagree
				Agree
				Strongly agree
				Not applicable
CAS0029040		What additional services would you like to see on My HealtheVet? (Please select all that apply)		Schedule or change my VA appointments		Checkbox, one-up vertical	Multi	N		Additional Services
				Track the status of my prescription refill delivery
				View/pay my VA bills/copayments
				View a list of my VA health care providers and their contact information
				Use a mobile app for My HealtheVet
				Join an online forum to discuss health issues with other Veterans
				Advance check-in for my VA clinic visits
				Andrea Fuhrel-Forbis: My HealtheVet is showing up with the little e underlined and italicized instead of bolded and italicised. Authorize sharing information I have stored in My HealtheVet with other people (e.g., family, caregiver)
				Authorize sharing information that I have stored in My HealtheVet with my VA health care team
				Authorize sharing information that I have stored in My HealtheVet with my Non-VA health care provider
				Check to determine if my different medications are safe when taken together
				More online educational programs
				Receive a monthly email newsletter
				Receive notification of new content/features on the site
				Other
ALM0173		What is the main improvement that you would suggest for the My HealtheVet web site?				Text area, no char limit		N		ENDRequest
AED06379		Have you completed this survey within the past 3 months?		Yes		Radio button, one-up vertical	Single	N		Survey
				No
				Don't recall

---

Sheet 5: Custom Qsts (3-13-14)

Model Instance Name: VA - My HealtheVet				red & strike-through: DELETE
MID:	NJxFtMU9UosBkJZRd48x9Q==			underlined & italicized: RE-ORDER
				pink: ADDITION
Date:	6/23/2009			blue + -->: REWORDING
20140110 - MHV Meaningful Use Wave 2 l Custom Questions.xlsx				violet (bold): SKIP-LOGIC	As programmed wave 2 Jan
MID: CUSTOM QUESTION LIST
QID	Skip Logic Label	Question Text	Answer IDs (DOT ONLY)	Answer Choices (limited to 50 characters)	Skip to	Type (select from list)	Single or Multi	Required Y/N	Special Instructions	Question Label
ALM0170		Which of the following best describes you?		Active duty		Checkbox, one-up vertical	Multi	Y		ANRole
				National Guard/Reserve
				Veteran
				Family member of a veteran or Servicemember
				Caregiver of a Veteran or Servicemember (other than family)
				Veteran Service Organization member
				VA employee
				Non-VA federal government employee
				State/local government employee
				General public
				Other role
RJB00048		Please indicate your military period(s) of service:		Global War on Terror (OEF/OIF/OND)		Checkbox, one-up vertical	Multi	N		ANMilServ
				Desert Shield/Desert Storm
				Vietnam War
				Korean War
				World War II
				Peacetime Service
				Other
		Mutually exclusive		Not Applicable
AED02714		What is your age range?		Under 20		Dropdown (Select-one)	Single	N		ANAge
				20-24
				25-29
				30-34
				35-39
				40-44
				45-49
				50-54
				55-59
				60-64
				65-69
				70-74
				75-79
				80-84
				85 or older
JIC00267		What is your gender?		Male		Dropdown (Select-one)	Single	N		ANGender
				Female
CAS0042785		Are you of Hispanic or Latino origin or descent?		Yes		Drop down, select one	Single	N		ANEthnicity
				No
CAS0042786		What is your race?		American Indian or Alaska Native		Drop down, select one	Single	N		ANRace
				Asian
				Black or African American
				Native Hawaiian or Other Pacific Islander
				White (Caucasian)
				Two or More Races
				Other race
				Unknown or Do Not Wish to Reply
CAS0028939		Which of the following best describes the highest level of education you have completed?		Did not complete high school		Radio button, one-up vertical	Single	Y		ANEduc
				High school graduate
				Some college or vocational school
				College graduate
				Some postgraduate school
				Graduate or professional degree
JIC00178		In general, how would you rate your overall health?		Excellent		Drop down, select one	Single	Y		ANHealth
				Very Good
				Good
				Fair
				Poor
RJB00026		Are you a registered user on the MyHealtheVet web site?		Yes	A	Checkbox, one-up vertical	Single	Y	Skip Logic	ANRegUser
				No
				Not sure
CAS0028940	A	Your member log-in box now includes an icon for your account type. What type of My HealtheVet account do you have?		Basic (B)		Checkbox, one-up vertical	Single	Y	Skip Logic	ANUserType
				Advanced (A)
				Premium (authenticated or IPA’d)(P)
				Not sure
ALM0169		How frequently do you visit the My HealtheVet web site?		First time		Dropdown (Select-one)	Single	Y		ANMHVFreq
				Daily or more than once a day
				About once a week
				About once a month
				About every 6 months
				Less than every 6 months
				Not sure/Do not recall
RJB00022		What were you trying to accomplish today in My HealtheVet? (pPlease select all that apply)		Learn more about features that are available		Checkbox, one-up vertical	Multi	Y		ANReason
				Request a prescription refill
				View my medication history
				Use Secure Messaging to communicate with my VA health care team
				Use the Blue Button (Download My Data)
				View my VA Appointments
				Look up information about a health condition or medication
				View my lab or other test results
				View my VA Wellness Reminders
				View my VA Notes (written by my health care team)
				Enter my personal information (emergency contacts, etc.)
				Enter data that I track myself such as weight, blood pressure, blood sugar, etc.
				Enter information about my non-VA medications or supplements
				Find a VA facility
				Find information about VA Health Benefits
				Find information about VA Benefits other than health benefits
				Other
ALM0172		Did you accomplish what you wanted to in My HealtheVet?		Yes		Dropdown (Select-one)	Single	Y		ANTaskAcc
				No
				Partially
				Not finished yet
		How did you look for information on/navigate the site today? (Please select all that apply)		Search feature		Checkbox, one-up vertical	Multi	Y		NavMethods
				Top navigation bar
				Links elsewhere on the page
				Quick links
				Used FAQs tab
				Used Learn More tab
				Set a bookmark in my browser to a specific page on the site
				Contacted the Help Desk
				Other /Do not recall
		How would you describe your navigation experience on My HealtheVet today? (Please select all that apply)		Andrea Fuhrel-Forbis: DOT: Please make this answer choice mutually exclusive and gray out other options if it is selected. I had no difficulty navigating/browsing on this site		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	NavExperience
				Links often did not take me where I expected
				Had difficulty finding relevant information
				Links/labels are difficult to understand
				Too many links/navigational options to choose from
				Had technical difficulties (error messages, broken links, etc.)	A
				Could not navigate back to previous information
				I had a navigation difficulty not listed above
	A	What type(s) of technical difficulties did you experience today? (Please select all that apply)		Page "updating"	B	Checkbox, one-up vertical	Multi	N	Skip Logic Group	TechDifficulties
				Page did not load completely	B
				Received an error message	B
				Clicked on links that were broken	B
				Page too slow to load	B
				Other technical difficulty not listed above	B
				Do not recall
	B	On which page(s) or feature(s) did you experience the technical difficulty? (Please select all that apply)		Home page		Checkbox, one-up vertical	Multi	N	Skip Logic Group	TechDiffPages
				Registering for an account
				Logging into my account
				Rx Refill
				Health calendar
				VA Blue Button
				VA CCD
				Veterans Health Library
				VA Appointments
				Secure Messaging
				Track health
				Other /Do not recall
CAS0028943		Do you get care at a VA facility?		Yes	A,B, C, D, E, F	Checkbox, one-up vertical	Single	Y	Skip Logic	ANFacilCare
				No
				Not Sure
CAS0028944	A	In the past year, how often did you use a VA medical facility or service for your health care needs?		Never		Checkbox, one-up vertical	Single	N	skip logic	ANFacilFreq
				Once in the past year
				2 to 11 times in the past year
				12 or more times in the past year
CAS0042864	B	What is your travel time to the VA facility where you receive most of your care?		less than 30 minutes		Radio button, one-up vertical	Single	Y	skip logic	ANDist
				30 minutes to under 1 hour
				1 hour to under 1.5 hours
				1.5 hours to under 2 hours
				2 or more hours
				Not sure/Do not recall
CAS0042867	C	How many years have you been seeing your VA primary healthcare team?		Less than 1 year		Drop down, select one	Single	Y		ANYrsTeam
				1-5 years
				More than 5 years
				Not sure/Do not recall
CAS0042868	D	Generally speaking, how satisfied are you with the quality of care and treatment that you receive from your VA healthcare team?		Very unsatisfied		Radio button, one-up vertical	Single	Y		ANSatTeam
				Unsatisfied
				Neither satisfied nor unsatisfied
				Satisfied
				Very satisfied
				Not sure/Do not recall
CAS0042869	E	Overall, I trust my VA healthcare team's advice and care.		Strongly disagree		Radio button, one-up vertical	Single	Y		ANTrustTeam
				Disagree
				Neither agree nor disagree
				Agree
				Strongly agree
				Not sure/Do not recall
CAS0042814	F	Has your VA doctor or healthcare team ever recommended Secure Messaging to you?		Yes		Radio button, one-up vertical	Single	Y		PREverUsed
				No
				Not Sure/Do Not Recall
NEW MEANINGFUL USE Wave 2 QUESTION ROTATION
[ORIENTING QUESTION]:
CAS0046942		Which of the following convinced you to first try My HealtheVet? (Please select all that apply)		My doctor uses it		Checkbox, one-up vertical	Multi	Y		PRTrial
				My doctor recommended it to me
				Someone on my VA healthcare team other than my doctor recommended it to me.
				Another Veteran recommended it to me
				I received a hands-on demonstration at the VA facility.
				I saw a video program or a poster at the VA facility.
				I read a printed fact sheet.
				I received a postcard.
				I received an email reminder.
				I received a phone call from the VA.
				I read or heard about it through the media (newspaper, radio, TV, or social media like Facebook or Twitter).
				I received or saw information materials provided in Spanish.
				Other
				Not sure/Do Not Recall
CAS0046943		How long have you been using My HealtheVet?		Less than 6 months		Radio button, one-up vertical	Single	Y		PRYrsUse
				6 months - less than 1 year
				1-2 years
				More than 2 years
				Not sure/Do Not Recall
[ORIENTING QUESTION]:
CAS0046944		In the past year, how frequently have you used the Blue Button to access your VA personal health record information?		Never		Radio button, one-up vertical	single	Y		PRTaskFreq1
				1-2 times
				3-9 times
				10 or more times
CAS0046945		In the past year, how frequently have you used Secure Messaging to communicate with your doctor or healthcare team?		Never		Radio button, one-up vertical	single	Y		PRTaskFreq2
				1-2 times
				3-9 times
				10 or more times
CAS0046946		In the past year, how frequently have you used My HealtheVet to check your upcoming VA appointments?		Never		Radio button, one-up vertical	single	Y		PRTaskFreq3
				1-2 times
				3-9 times
				10 or more times
CAS0046947		In the past year, how frequently have you used My HealtheVet to request a prescription refill?		Never		Radio button, one-up vertical	single	Y		PRTaskFreq4
				1-2 times
				3-9 times
				10 or more times
CAS0046948		In the past year, how frequently have you used My HealtheVet to check your VA prescription history?		Never		Radio button, one-up vertical	Multi	Y		PRMedFreq5
				1-2 times
				3-9 times
				10 or more times
CAS0046949		In the past year, how frequently have you used My HealtheVet Blue Button to check your VA Notes (the visit notes written by your VA healthcare team)?		Never		Radio button, one-up vertical	single	Y		PRTaskFreq6
				1-2 times
				3-9 times
				10 or more times
CAS0046950		In the past year, how frequently have you used My HealtheVet to check on your lab or test results (for example: blood tests, pathology reports, radiology reports, etc.)?		Never		Radio button, one-up vertical	single	Y		PRTaskFreq7
				1-2 times
				3-9 times
				10 or more times
CAS0046951		In the past year, how frequently have you used My HealtheVet to check your vitals and readings?		Never		Radio button, one-up vertical	single	Y		PRTaskFreq8
				1-2 times
				3-9 times
				10 or more times
CAS0046952		In the past year, how frequently have you used My HealtheVet to check your health summary using the VA Continuity of Care Document (VA CCD)?		Never		Radio button, one-up vertical	single	Y		PRTaskFreq9
				1-2 times
				3-9 times
				10 or more times
CAS0046953		In the past year, which of the following other types of information have you accessed in My HealtheVet or the VA Blue Button? (Please select all that apply)				Radio button, one-up vertical	Multi	Y		PROTaskFreq
				VA Allergies and Adverse Reactions
				VA Immunizations
				VA Problem List (active health issues and conditions)
				VA Admissions and Discharges
				VA Wellness Reminders (for example: shots, cancer screening)
				Department of Defense (DoD) Military Service Information
				None of the above
[ORIENTING QUESTION]:
CAS0046954		In the past year, how frequently have you used My HealtheVet to self-enter your medications and supplements?		Never		Radio button, one-up vertical	single	Y		PRSEFreq1
				1-2 times
				3-9 times
				10 or more times
CAS0046955		In the past year, how frequently have you used My HealtheVet to self-enter your lab and test results?		Never		Radio button, one-up vertical	single	Y		PRSEFreq2
				1-2 times
				3-9 times
				10 or more times
CAS0046956		In the past year, how frequently have you used My HealtheVet to self-enter your allergies and adverse reactions?		Never		Radio button, one-up vertical	single	Y		PRSEFreq3
				1-2 times
				3-9 times
				10 or more times
CAS0046957		In the past year, how frequently have you used My HealtheVet to self-enter your vitals and readings?		Never		Radio button, one-up vertical	single	Y		PRSEFreq4
				1-2 times
				3-9 times
				10 or more times
CAS0046958		In the past year, how frequently have you used My HealtheVet to self-enter information in your food journal?		Never		Radio button, one-up vertical	single	Y		PRSEFreq5
				1-2 times
				3-9 times
				10 or more times
CAS0046959		In the past year, how frequently have you used My HealtheVet to self-enter information in your activity journal?		Never		Radio button, one-up vertical	single	Y		PRSEFreq6
				1-2 times
				3-9 times
				10 or more times
CAS0046924		In the past year, how frequently have you used the My Goals feature in My HealtheVet to self-enter your health goals?		Never		Radio button, one-up vertical	single	Y		PRSEFreq7
				1-2 times
				3-9 times
				10 or more times
CAS0046925		In the past year, which other types of information have you self-entered into your My HealtheVet personal health record? (Please select all that apply)				Radio button, one-up vertical	Multi	Y		PRSEOFreq
				Immunizations, self-reported
				Medical events, self-reported
				Family health history, self-reported
				Military health history, self-reported
				Treatment facility, self-reported
				Health insurance, self-reported
				Caregiver names and contacts, self-reported
				Health calendar, self-reported
				Personal information (contact information, emergency contacts), self-reported
				None of the above
[ORIENTING QUESTION]:
CAS0046926		In the past year, how frequently have you communicated with your VA primary healthcare team about information that you self-entered into My HealtheVet? (for example: your home blood glucose or blood pressure measurements)		Never		Radio button, one-up vertical		Y		PRVASelfFreq
				1-2 times
				3-9 times
				10 or more times
CAS0046927		In the past year, how frequently have you communicated with your VA primary healthcare team about information that you accessed from your VA medical record in My HealtheVet? (for example: your VA Notes)		Never		Radio button, one-up vertical		Y		PRVAMHVFreq
				1-2 times
				3-9 times
				10 or more times
CAS0046928		In the past year, how frequently have you communicated with your other VA healthcare providers (for example: your specialist physicians, therapists, counselors and coordinators) about information that you self-entered into My HealtheVet?		Never		Radio button, one-up vertical		Y		PROtherSelfFreq
				1-2 times
				3-9 times
				10 or more times
CAS0046962		In the past year, how frequently have you communicated with your other VA healthcare providers (for example: your specialist physicians, therapists, counselors and coordinators) about information that you accessed from your VA medical record in My HealtheVet? (for example: your VA Notes)		Never		Radio button, one-up vertical		Y		PROtherMHVFreq
				1-2 times
				3-9 times
				10 or more times
CAS0046963		In the past year, how frequently have you used My HealtheVet information when you communicated with your VA healthcare team about care you received outside of the VA? (for example: tests done elsewhere or a non-VA emergency department visit)		Never		Radio button, one-up vertical	single	Y		PROutsideCare
				1-2 times
				3-9 times
				10 or more times
CAS0046964		In the past year, how frequently have you used My HealtheVet information when you communicated with your non-VA providers about care you received at the VA?		Never		Radio button, one-up vertical	single	Y		PRNonVAProvider
				1-2 times
				3-9 times
				10 or more times
				I do not have any non-VA providers
CAS0046964		Which of the following methods do you use to access the My HealtheVet website? (Please select all that apply)		Computer or laptop		Checkbox, one-up vertical	Multi	Y		PRDevice
				Mobile phone (for example: iPhone, Android)
				Mobile tablet (for example: iPad, Android)
				Kiosk
				Television (for example: interactive Web TV )
				Other
[ORIENTING INTRODUCTION]		Your feedback is very important to us. Please think about your use of My HealtheVet features other than Secure Messaging when answering the following questions.
CAS0046966		The information in My HealtheVet is accurate.		Strongly disagree		Radio button, one-up vertical	Single	Y		PRAccurate
				Disagree
				Neither agree nor disagree
				Agree
				Strongly agree
				Not sure/Do Not Recall
CAS0046967		The information in My HealtheVet is easy to understand.		Strongly disagree		Radio button, one-up vertical	Single	Y		PREasy
				Disagree
				Neither agree nor disagree
				Agree
				Strongly agree
				Not sure/Do Not Recall
CAS0046968		New or updated information in My HealtheVet is generally available to me in a timely manner.		Strongly disagree		Radio button, one-up vertical	Single	Y		PRTimely
				Disagree
				Neither agree nor disagree
				Agree
				Strongly agree
				Not sure/Do Not Recall
CAS0046969		My HealtheVet is a reliable system. (That is, I can always count on it working.)		Strongly disagree		Radio button, one-up vertical	Single	Y		PRProtect
				Disagree
				Neither agree nor disagree
				Agree
				Strongly agree
				Not sure/Do Not Recall
CAS0046970		I am confident that My HealtheVet protects the privacy and security of my personal health information.		Strongly disagree		Radio button, one-up vertical	Single	Y		PRPrivate
				Disagree
				Neither agree nor disagree
				Agree
				Strongly agree
				Not sure/Do Not Recall
CAS0046971		It is easy to find the different My HealtheVet features that I want to use.		Strongly disagree		Radio button, one-up vertical	Single	Y		PRONavToSM
				Disagree
				Neither agree nor disagree
				Agree
				Strongly agree
				Not sure/Do Not Recall
CAS0046972		It is easy to navigate within the My HealtheVet features (for example, checking my VA Prescription status then requesting a refill).		Strongly disagree		Radio button, one-up vertical	Single	Y		PRNavInSM
				Disagree
				Neither agree nor disagree
				Agree
				Strongly agree
				Not sure/Do Not Recall
CAS0046973		I trust my healthcare information when I receive it through My HealtheVet.		Strongly disagree		Radio button, one-up vertical	Single	Y		PRTrustOnline
				Disagree
				Neither agree nor disagree
				Agree
				Strongly agree
				Not sure/Do Not Recall
CAS0046974		Regarding my personal health goals, I use My HealtheVet to help me: (Please select all that apply)				Checkbox, one-up vertical	Multi	Y		PRGoals
				Self-enter and track my personal health goals
				Gain peace of mind about my personal health goals
				Coordinate with my VA healthcare team based on my personal health goals
				None of the above
CAS0046975		Regarding my VA medications, I use My HealtheVet to help me: (Please select all that apply)				Checkbox, one-up vertical	Multi	Y		PRMeds
				Review and understand my VA-prescribed medications
				Gain peace of mind about my VA-prescribed medications
				Coordinate with my VA healthcare team about my VA-prescribed medications
				None of the above
CAS0046929		Regarding my VA tests and procedures, I use My HealtheVet to help me: (Please select all that apply)				Checkbox, one-up vertical	Multi	Y		PRTestPRoc
				Review and understand the tests and procedures that I receive from VA
				Gain peace of mind from my VA healthcare team about tests and procedures that I receive from VA
				Coordinate with my VA healthcare team about the tests and procedures that I receive from VA
				None of the above
CAS0046930		Regarding my mental and emotional health, I use My HealtheVet to help me: (Please select all that apply)				Checkbox, one-up vertical	Multi	Y		PRMentalHealth
				Review and understand my mental and emotional health and any prescribed treatment
				Gain peace of mind about my mental and emotional health and any prescribed treatment
				Coordinate with my VA healthcare team about my mental and emotional health and any prescribed treatment
				None of the above
CAS0046931		Regarding my VA preventive care (for example: screenings for type 2 diabetes, cholesterol, depression), I use My HealtheVet to help me: (Please select all that apply)				Checkbox, one-up vertical	Multi	Y		PRPreventive
				Review and understand my VA preventive care
				Gain peace of mind about my VA preventive care
				Coordinate with my VA healthcare team about my VA preventive care
				None of the above
CAS0046932		Regarding things I can do for my health (such as diet and exercise), I use My HealtheVet to help me: (Please select all that apply)		Review and understand specific things I can do to improve my health or prevent illness		Checkbox, one-up vertical	Multi	Y		PRSelfCare
				Self-enter and track specific things I can do to improve my health or prevent illness
				Gain peace of mind about specific things I can do to improve my health or prevent illness
				Coordinate with my VA healthcare team about specific things I can do to improve my health or prevent illness
				None of the above
CAS0046933		After treatment, labs or tests, I review my results on My HealtheVet to see if I need a follow-up call or visit.		Strongly disagree		Radio button, one-up vertical	Single	Y		PRFollowUp
				Disagree
				Neither agree nor disagree
				Agree
				Strongly agree
CAS0046934		I use My HealtheVet information to help me make better health and healthcare decisions.		Strongly disagree		Radio button, one-up vertical	Single	Y		PRDecisInfo
				Disagree
				Neither agree nor disagree
				Agree
				Strongly agree
CAS0046935		I use My HealtheVet to help me judge when it is necessary to call or go see my VA healthcare team.		Strongly disagree		Radio button, one-up vertical	Single	Y		PRDecisCall
				Disagree
				Neither agree nor disagree
				Agree
				Strongly agree
CAS0046936		I use My HealtheVet to help me figure out solutions when new problems arise with my health.		Strongly disagree		Radio button, one-up vertical	Single	Y		PRSolutions
				Disagree
				Neither agree nor disagree
				Agree
				Strongly agree
CAS0046937		I have all the information I need to manage my health and healthcare.		Strongly disagree		Radio button, one-up vertical	Single	Y		OUTInfo
				Disagree
				Neither agree nor disagree
				Agree
				Strongly agree
CAS0046938		I am confident in working with my VA healthcare team to manage my health and healthcare.		Strongly disagree		Radio button, one-up vertical	Single	Y		OUTTeam
				Disagree
				Neither agree nor disagree
				Agree
				Strongly agree
CAS0046939		I feel in control of my health and healthcare (such as taking part in decisions or following through on any medication, treatment or health routine).		Strongly disagree		Radio button, one-up vertical	Single	Y		OUTControl
				Disagree
				Neither agree nor disagree
				Agree
				Strongly agree
CAS0046940		I am able to achieve my long-term health and healthcare goals (such as being self-reliant, living longer and better, or knowing that my family and friends can depend on me.)		Strongly disagree		Radio button, one-up vertical	Single	Y		OUTAchGoals
				Disagree
				Neither agree nor disagree
				Agree
				Strongly agree
CAS0046941		I intend to continue using My HealtheVet in the future.		Strongly disagree		Radio button, one-up vertical	Single	Y		OUTIntentUse
				Disagree
				Neither agree nor disagree
				Agree
				Strongly agree
CAS0046982		I intend to recommend My HealtheVet to others.		Strongly disagree		Radio button, one-up vertical	Single	Y		OUTIntentRec
				Disagree
				Neither agree nor disagree
				Agree
				Strongly agree
CAS0042904		How often do you find that information from the VA (in print or online) about your medical condition is difficult to understand?		Never or almost never		Radio button, one-up vertical	Single	Y		ANHlthLit
				Infrequently
				Occasionally
				Frequently
				Very frequently or always
				Not sure/Do not recall
RJB00029		My use of the My HealtheVet personal health record has improved my ability to manage my health.		Strongly disagree		Radio button, one-up vertical	Single	Y		MHV improve Health
				Disagree
				Not sure
				Disagree
				Agree
				Strongly agree
				Not applicable
CAS0042905		Overall, how confident are you that you could get health-related advice or information if you needed it by using a computer, smart phone or tablet (like an iPhone or iPad)?		Not at all confident		Radio button, one-up vertical	Single	Y		ANHlthSearch
				Somewhat confident
				Moderately confident
				Confident
				Very confident
				Not sure
CAS0029040		What additional services would you like to see on My HealtheVet? (Please select all that apply)		Schedule or change my VA appointments		Checkbox, one-up vertical	Multi	N		Additional Services
				Track the status of my prescription refill delivery
				View/pay my VA bills/copayments
				View a list of my VA health care providers and their contact information
				Use a mobile app for My HealtheVet
				Join an online forum to discuss health issues with other Veterans
				Advance check-in for my VA clinic visits
				Authorize sharing information I have stored in My HealtheVet with other people (e.g., family, caregiver)
				Authorize sharing information that I have stored in My HealtheVet with my VA health care team
				Authorize sharing information that I have stored in My HealtheVet with my Non-VA health care provider
				Check to determine if my different medications are safe when taken together
				More online educational programs
				Receive a monthly email newsletter
				Receive notification of new content/features on the site
				Other
ALM0173		What is the main improvement that you would suggest for the My HealtheVet web site?				Text area, no char limit		N		ENDRequest
AED06379		Have you completed this survey within the past 3 months?		Yes		Radio button, one-up vertical				Survey
				No			Single	N
				Don't recall

---

Sheet 6: Current Custom Qsts (3-7-14)

Model Instance Name: VA - My HealtheVet				red & strike-through: DELETE
MID:	NJxFtMU9UosBkJZRd48x9Q==			underlined & italicized: RE-ORDER
				pink: ADDITION
Date:	6/23/2009			blue + -->: REWORDING
20140110 - MHV Meaningful Use Wave 2 l Custom Questions.xlsx				violet (bold): SKIP-LOGIC	As programmed wave 2 Jan
MID: CUSTOM QUESTION LIST
QID	Skip Logic Label	Question Text	Answer IDs (DOT ONLY)	Answer Choices (limited to 50 characters)	Skip to	Type (select from list)	Single or Multi	Required Y/N	Special Instructions	Question Label
ALM0170		Which of the following best describes you?		Active duty		Checkbox, one-up vertical	Multi	Y		ANRole
				National Guard/Reserve
				Veteran
				Family member of a veteran or Servicemember
				Caregiver of a Veteran or Servicemember (other than family)
				Veteran Service Organization member
				VA employee
				Non-VA federal government employee
				State/local government employee
				General public
				Other role
RJB00048		Please indicate your military period(s) of service:		Global War on Terror (OEF/OIF/OND)		Checkbox, one-up vertical	Multi	N		ANMilServ
				Desert Shield/Desert Storm
				Vietnam War
				Korean War
				World War II
				Peacetime Service
				Other
		Mutually exclusive		Not Applicable
AED02714		What is your age range?		Under 20		Dropdown (Select-one)	Single	N		ANAge
				20-24
				25-29
				30-34
				35-39
				40-44
				45-49
				50-54
				55-59
				60-64
				65-69
				70-74
				75-79
				80-84
				85 or older
JIC00267		What is your gender?		Male		Dropdown (Select-one)	Single	N		ANGender
				Female
CAS0042785		Are you of Hispanic or Latino origin or descent?		Yes		Drop down, select one	Single	N		ANEthnicity
				No
CAS0042786		What is your race?		American Indian or Alaska Native		Drop down, select one	Single	N		ANRace
				Asian
				Black or African American
				Native Hawaiian or Other Pacific Islander
				White (Caucasian)
				Two or More Races
				Other race
				Unknown or Do Not Wish to Reply
CAS0028939		Which of the following best describes the highest level of education you have completed?		Did not complete high school		Radio button, one-up vertical	Single	Y		ANEduc
				High school graduate
				Some college or vocational school
				College graduate
				Some postgraduate school
				Graduate or professional degree
JIC00178		In general, how would you rate your overall health?		Excellent		Drop down, select one	Single	Y		ANHealth
				Very Good
				Good
				Fair
				Poor
RJB00026		Are you a registered user on the MyHealtheVet web site?		Yes	A	Checkbox, one-up vertical	Single	Y	Skip Logic	ANRegUser
				No
				Not sure
CAS0028940	A	Your member log-in box now includes an icon for your account type. What type of My HealtheVet account do you have?		Basic (B)		Checkbox, one-up vertical	Single	Y	Skip Logic	ANUserType
				Advanced (A)
				Premium (authenticated or IPA’d)(P)
				Not sure
ALM0169		How frequently do you visit the My HealtheVet web site?		First time		Dropdown (Select-one)	Single	Y		ANMHVFreq
				Daily or more than once a day
				About once a week
				About once a month
				About every 6 months
				Less than every 6 months
				Not sure/Do not recall
RJB00022		What were you trying to accomplish today in My HealtheVet? (please select all that apply)				Checkbox, one-up vertical	Multi	Y		ANReason
				Learn more about features that are available
				Request a prescription refill
				View my medication history
				Use Secure Messaging to communicate with my VA health care team
				Use the Blue Button (Download My Data)
				View my VA Appointments
				Look up information about a health condition or medication
				View my lab or other test results
				View my VA Wellness Reminders
				View my VA Notes (written by my health care team)
				Enter my personal information (emergency contacts, etc.)
				Enter data that I track myself such as weight, blood pressure, blood sugar, etc.
				Enter information about my non-VA medications or supplements
				Find a VA facility
				Find information about VA Health Benefits
				Find information about VA Benefits other than health benefits
				Other
ALM0172		Did you accomplish what you wanted to in My HealtheVet?		Yes		Dropdown (Select-one)	Single	Y		ANTaskAcc
				No
				Partially
				Not finished yet
CAS0028943		Do you get care at a VA facility?		Yes	A,B, C, D, E, F	Checkbox, one-up vertical	Single	Y	Skip Logic	ANFacilCare
				No
				Not Sure
CAS0028944	A	In the past year, how often did you use a VA medical facility or service for your health care needs?		Never		Checkbox, one-up vertical	Single	N	skip logic	ANFacilFreq
				Once in the past year
				2 to 11 times in the past year
				12 or more times in the past year
CAS0042864	B	What is your travel time to the VA facility where you receive most of your care?		less than 30 minutes		Radio button, one-up vertical	Single	Y	skip logic	ANDist
				30 minutes to under 1 hour
				1 hour to under 1.5 hours
				1.5 hours to under 2 hours
				2 or more hours
				Not sure/Do not recall
CAS0042867	C	How many years have you been seeing your VA primary healthcare team?		Less than 1 year		Drop down, select one	Single	Y		ANYrsTeam
				1-5 years
				More than 5 years
				Not sure/Do not recall
CAS0042868	D	Generally speaking, how satisfied are you with the quality of care and treatment that you receive from your VA healthcare team?		Very unsatisfied		Radio button, one-up vertical	Single	Y		ANSatTeam
				Unsatisfied
				Neither satisfied nor unsatisfied
				Satisfied
				Very satisfied
				Not sure/Do not recall
CAS0042869	E	Overall, I trust my VA healthcare team's advice and care.		Strongly disagree		Radio button, one-up vertical	Single	Y		ANTrustTeam
				Disagree
				Neither agree nor disagree
				Agree
				Strongly agree
				Not sure/Do not recall
CAS0042814	F	Has your VA doctor or healthcare team ever recommended Secure Messaging to you?		Yes		Radio button, one-up vertical	Single	Y		PREverUsed
				No
				Not Sure/Do Not Recall
NEW MEANINGFUL USE Wave 2 QUESTION ROTATION
[ORIENTING QUESTION]:
CAS0046942		Which of the following convinced you to first try My HealtheVet? (Please select all that apply)		My doctor uses it		Checkbox, one-up vertical	Multi	Y		PRTrial
				My doctor recommended it to me
				Someone on my VA healthcare team other than my doctor recommended it to me.
				Another Veteran recommended it to me
				I received a hands-on demonstration at the VA facility.
				I saw a video program or a poster at the VA facility.
				I read a printed fact sheet.
				I received a postcard.
				I received an email reminder.
				I received a phone call from the VA.
				I read or heard about it through the media (newspaper, radio, TV, or social media like Facebook or Twitter).
				I received or saw information materials provided in Spanish.
				Other
				Not sure/Do Not Recall
CAS0046943		How long have you been using My HealtheVet?		Less than 6 months		Radio button, one-up vertical	Single	Y		PRYrsUse
				6 months - less than 1 year
				1-2 years
				More than 2 years
				Not sure/Do Not Recall
[ORIENTING QUESTION]:
CAS0046944		In the past year, how frequently have you used the Blue Button to access your VA personal health record information?		Never		Radio button, one-up vertical	single	Y		PRTaskFreq1
				1-2 times
				3-9 times
				10 or more times
CAS0046945		In the past year, how frequently have you used Secure Messaging to communicate with your doctor or healthcare team?		Never		Radio button, one-up vertical	single	Y		PRTaskFreq2
				1-2 times
				3-9 times
				10 or more times
CAS0046946		In the past year, how frequently have you used My HealtheVet to check your upcoming VA appointments?		Never		Radio button, one-up vertical	single	Y		PRTaskFreq3
				1-2 times
				3-9 times
				10 or more times
CAS0046947		In the past year, how frequently have you used My HealtheVet to request a prescription refill?		Never		Radio button, one-up vertical	single	Y		PRTaskFreq4
				1-2 times
				3-9 times
				10 or more times
CAS0046948		In the past year, how frequently have you used My HealtheVet to check your VA prescription history?		Never		Radio button, one-up vertical	Multi	Y		PRMedFreq5
				1-2 times
				3-9 times
				10 or more times
CAS0046949		In the past year, how frequently have you used My HealtheVet Blue Button to check your VA Notes (the visit notes written by your VA healthcare team)?		Never		Radio button, one-up vertical	single	Y		PRTaskFreq6
				1-2 times
				3-9 times
				10 or more times
CAS0046950		In the past year, how frequently have you used My HealtheVet to check on your lab or test results (for example: blood tests, pathology reports, radiology reports, etc.)?		Never		Radio button, one-up vertical	single	Y		PRTaskFreq7
				1-2 times
				3-9 times
				10 or more times
CAS0046951		In the past year, how frequently have you used My HealtheVet to check your vitals and readings?		Never		Radio button, one-up vertical	single	Y		PRTaskFreq8
				1-2 times
				3-9 times
				10 or more times
CAS0046952		In the past year, how frequently have you used My HealtheVet to check your health summary using the VA Continuity of Care Document (VA CCD)?		Never		Radio button, one-up vertical	single	Y		PRTaskFreq9
				1-2 times
				3-9 times
				10 or more times
CAS0046953		In the past year, which of the following other types of information have you accessed in My HealtheVet or the VA Blue Button? (Please select all that apply)				Radio button, one-up vertical	Multi	Y		PROTaskFreq
				VA Allergies and Adverse Reactions
				VA Immunizations
				VA Problem List (active health issues and conditions)
				VA Admissions and Discharges
				VA Wellness Reminders (for example: shots, cancer screening)
				Department of Defense (DoD) Military Service Information
				None of the above
[ORIENTING QUESTION]:
CAS0046954		In the past year, how frequently have you used My HealtheVet to self-enter your medications and supplements?		Never		Radio button, one-up vertical	single	Y		PRSEFreq1
				1-2 times
				3-9 times
				10 or more times
CAS0046955		In the past year, how frequently have you used My HealtheVet to self-enter your lab and test results?		Never		Radio button, one-up vertical	single	Y		PRSEFreq2
				1-2 times
				3-9 times
				10 or more times
CAS0046956		In the past year, how frequently have you used My HealtheVet to self-enter your allergies and adverse reactions?		Never		Radio button, one-up vertical	single	Y		PRSEFreq3
				1-2 times
				3-9 times
				10 or more times
CAS0046957		In the past year, how frequently have you used My HealtheVet to self-enter your vitals and readings?		Never		Radio button, one-up vertical	single	Y		PRSEFreq4
				1-2 times
				3-9 times
				10 or more times
CAS0046958		In the past year, how frequently have you used My HealtheVet to self-enter information in your food journal?		Never		Radio button, one-up vertical	single	Y		PRSEFreq5
				1-2 times
				3-9 times
				10 or more times
CAS0046959		In the past year, how frequently have you used My HealtheVet to self-enter information in your activity journal?		Never		Radio button, one-up vertical	single	Y		PRSEFreq6
				1-2 times
				3-9 times
				10 or more times
CAS0046924		In the past year, how frequently have you used the My Goals feature in My HealtheVet to self-enter your health goals?		Never		Radio button, one-up vertical	single	Y		PRSEFreq7
				1-2 times
				3-9 times
				10 or more times
CAS0046925		In the past year, which other types of information have you self-entered into your My HealtheVet personal health record? (Please select all that apply)				Radio button, one-up vertical	Multi	Y		PRSEOFreq
				Immunizations, self-reported
				Medical events, self-reported
				Family health history, self-reported
				Military health history, self-reported
				Treatment facility, self-reported
				Health insurance, self-reported
				Caregiver names and contacts, self-reported
				Health calendar, self-reported
				Personal information (contact information, emergency contacts), self-reported
				None of the above
[ORIENTING QUESTION]:
CAS0046926		In the past year, how frequently have you communicated with your VA primary healthcare team about information that you self-entered into My HealtheVet? (for example: your home blood glucose or blood pressure measurements)		Never		Radio button, one-up vertical		Y		PRVASelfFreq
				1-2 times
				3-9 times
				10 or more times
CAS0046927		In the past year, how frequently have you communicated with your VA primary healthcare team about information that you accessed from your VA medical record in My HealtheVet? (for example: your VA Notes)		Never		Radio button, one-up vertical		Y		PRVAMHVFreq
				1-2 times
				3-9 times
				10 or more times
CAS0046928		In the past year, how frequently have you communicated with your other VA healthcare providers (for example: your specialist physicians, therapists, counselors and coordinators) about information that you self-entered into My HealtheVet?		Never		Radio button, one-up vertical		Y		PROtherSelfFreq
				1-2 times
				3-9 times
				10 or more times
CAS0046962		In the past year, how frequently have you communicated with your other VA healthcare providers (for example: your specialist physicians, therapists, counselors and coordinators) about information that you accessed from your VA medical record in My HealtheVet? (for example: your VA Notes)		Never		Radio button, one-up vertical		Y		PROtherMHVFreq
				1-2 times
				3-9 times
				10 or more times
CAS0046963		In the past year, how frequently have you used My HealtheVet information when you communicated with your VA healthcare team about care you received outside of the VA? (for example: tests done elsewhere or a non-VA emergency department visit)		Never		Radio button, one-up vertical	single	Y		PROutsideCare
				1-2 times
				3-9 times
				10 or more times
CAS0046964		In the past year, how frequently have you used My HealtheVet information when you communicated with your non-VA providers about care you received at the VA?		Never		Radio button, one-up vertical	single	Y		PRNonVAProvider
				1-2 times
				3-9 times
				10 or more times
				I do not have any non-VA providers
CAS0046964		Which of the following methods do you use to access the My HealtheVet website? (Please select all that apply)		Computer or laptop		Checkbox, one-up vertical	Multi	Y		PRDevice
				Mobile phone (for example: iPhone, Android)
				Mobile tablet (for example: iPad, Android)
				Kiosk
				Television (for example: interactive Web TV )
				Other
[ORIENTING INTRODUCTION]		Your feedback is very important to us. Please think about your use of My HealtheVet features other than Secure Messaging when answering the following questions.
CAS0046966		The information in My HealtheVet is accurate.		Strongly disagree		Radio button, one-up vertical	Single	Y		PRAccurate
				Disagree
				Neither agree nor disagree
				Agree
				Strongly agree
				Not sure/Do Not Recall
CAS0046967		The information in My HealtheVet is easy to understand.		Strongly disagree		Radio button, one-up vertical	Single	Y		PREasy
				Disagree
				Neither agree nor disagree
				Agree
				Strongly agree
				Not sure/Do Not Recall
CAS0046968		New or updated information in My HealtheVet is generally available to me in a timely manner.		Strongly disagree		Radio button, one-up vertical	Single	Y		PRTimely
				Disagree
				Neither agree nor disagree
				Agree
				Strongly agree
				Not sure/Do Not Recall
CAS0046969		My HealtheVet is a reliable system. (That is, I can always count on it working.)		Strongly disagree		Radio button, one-up vertical	Single	Y		PRProtect
				Disagree
				Neither agree nor disagree
				Agree
				Strongly agree
				Not sure/Do Not Recall
CAS0046970		I am confident that My HealtheVet protects the privacy and security of my personal health information.		Strongly disagree		Radio button, one-up vertical	Single	Y		PRPrivate
				Disagree
				Neither agree nor disagree
				Agree
				Strongly agree
				Not sure/Do Not Recall
CAS0046971		It is easy to find the different My HealtheVet features that I want to use.		Strongly disagree		Radio button, one-up vertical	Single	Y		PRONavToSM
				Disagree
				Neither agree nor disagree
				Agree
				Strongly agree
				Not sure/Do Not Recall
CAS0046972		It is easy to navigate within the My HealtheVet features (for example, checking my VA Prescription status then requesting a refill).		Strongly disagree		Radio button, one-up vertical	Single	Y		PRNavInSM
				Disagree
				Neither agree nor disagree
				Agree
				Strongly agree
				Not sure/Do Not Recall
CAS0046973		I trust my healthcare information when I receive it through My HealtheVet.		Strongly disagree		Radio button, one-up vertical	Single	Y		PRTrustOnline
				Disagree
				Neither agree nor disagree
				Agree
				Strongly agree
				Not sure/Do Not Recall
CAS0046974		Regarding my personal health goals, I use My HealtheVet to help me: (Please select all that apply)				Checkbox, one-up vertical	Multi	Y		PRGoals
				Self-enter and track my personal health goals
				Gain peace of mind about my personal health goals
				Coordinate with my VA healthcare team based on my personal health goals
				None of the above
CAS0046975		Regarding my VA medications, I use My HealtheVet to help me: (Please select all that apply)				Checkbox, one-up vertical	Multi	Y		PRMeds
				Review and understand my VA-prescribed medications
				Gain peace of mind about my VA-prescribed medications
				Coordinate with my VA healthcare team about my VA-prescribed medications
				None of the above
CAS0046929		Regarding my VA tests and procedures, I use My HealtheVet to help me: (Please select all that apply)				Checkbox, one-up vertical	Multi	Y		PRTestPRoc
				Review and understand the tests and procedures that I receive from VA
				Gain peace of mind from my VA healthcare team about tests and procedures that I receive from VA
				Coordinate with my VA healthcare team about the tests and procedures that I receive from VA
				None of the above
CAS0046930		Regarding my mental and emotional health, I use My HealtheVet to help me: (Please select all that apply)				Checkbox, one-up vertical	Multi	Y		PRMentalHealth
				Review and understand my mental and emotional health and any prescribed treatment
				Gain peace of mind about my mental and emotional health and any prescribed treatment
				Coordinate with my VA healthcare team about my mental and emotional health and any prescribed treatment
				None of the above
CAS0046931		Regarding my VA preventive care (for example: screenings for type 2 diabetes, cholesterol, depression), I use My HealtheVet to help me: (Please select all that apply)				Checkbox, one-up vertical	Multi	Y		PRPreventive
				Review and understand my VA preventive care
				Gain peace of mind about my VA preventive care
				Coordinate with my VA healthcare team about my VA preventive care
				None of the above
CAS0046932		Regarding things I can do for my health (such as diet and exercise), I use My HealtheVet to help me: (Please select all that apply)		Review and understand specific things I can do to improve my health or prevent illness		Checkbox, one-up vertical	Multi	Y		PRSelfCare
				Self-enter and track specific things I can do to improve my health or prevent illness
				Gain peace of mind about specific things I can do to improve my health or prevent illness
				Coordinate with my VA healthcare team about specific things I can do to improve my health or prevent illness
				None of the above
CAS0046933		After treatment, labs or tests, I review my results on My HealtheVet to see if I need a follow-up call or visit.		Strongly disagree		Radio button, one-up vertical	Single	Y		PRFollowUp
				Disagree
				Neither agree nor disagree
				Agree
				Strongly agree
CAS0046934		I use My HealtheVet information to help me make better health and healthcare decisions.		Strongly disagree		Radio button, one-up vertical	Single	Y		PRDecisInfo
				Disagree
				Neither agree nor disagree
				Agree
				Strongly agree
CAS0046935		I use My HealtheVet to help me judge when it is necessary to call or go see my VA healthcare team.		Strongly disagree		Radio button, one-up vertical	Single	Y		PRDecisCall
				Disagree
				Neither agree nor disagree
				Agree
				Strongly agree
CAS0046936		I use My HealtheVet to help me figure out solutions when new problems arise with my health.		Strongly disagree		Radio button, one-up vertical	Single	Y		PRSolutions
				Disagree
				Neither agree nor disagree
				Agree
				Strongly agree
CAS0046937		I have all the information I need to manage my health and healthcare.		Strongly disagree		Radio button, one-up vertical	Single	Y		OUTInfo
				Disagree
				Neither agree nor disagree
				Agree
				Strongly agree
CAS0046938		I am confident in working with my VA healthcare team to manage my health and healthcare.		Strongly disagree		Radio button, one-up vertical	Single	Y		OUTTeam
				Disagree
				Neither agree nor disagree
				Agree
				Strongly agree
CAS0046939		I feel in control of my health and healthcare (such as taking part in decisions or following through on any medication, treatment or health routine).		Strongly disagree		Radio button, one-up vertical	Single	Y		OUTControl
				Disagree
				Neither agree nor disagree
				Agree
				Strongly agree
CAS0046940		I am able to achieve my long-term health and healthcare goals (such as being self-reliant, living longer and better, or knowing that my family and friends can depend on me.)		Strongly disagree		Radio button, one-up vertical	Single	Y		OUTAchGoals
				Disagree
				Neither agree nor disagree
				Agree
				Strongly agree
CAS0046941		I intend to continue using My HealtheVet in the future.		Strongly disagree		Radio button, one-up vertical	Single	Y		OUTIntentUse
				Disagree
				Neither agree nor disagree
				Agree
				Strongly agree
CAS0046982		I intend to recommend My HealtheVet to others.		Strongly disagree		Radio button, one-up vertical	Single	Y		OUTIntentRec
				Disagree
				Neither agree nor disagree
				Agree
				Strongly agree
CAS0042904		How often do you find that information from the VA (in print or online) about your medical condition is difficult to understand?		Never or almost never		Radio button, one-up vertical	Single	Y		ANHlthLit
				Infrequently
				Occasionally
				Frequently
				Very frequently or always
				Not sure/Do not recall
RJB00029		My use of the My HealtheVet personal health record has improved my ability to manage my health.		Strongly disagree		Radio button, one-up vertical	Single	Y		MHV improve Health
				Disagree
				Not sure
				Disagree
				Agree
				Strongly agree
				Not applicable
CAS0042905		Overall, how confident are you that you could get health-related advice or information if you needed it by using a computer, smart phone or tablet (like an iPhone or iPad)?		Not at all confident		Radio button, one-up vertical	Single	Y		ANHlthSearch
				Somewhat confident
				Moderately confident
				Confident
				Very confident
				Not sure
CAS0029040		What additional services would you like to see on My HealtheVet? (Please select all that apply)		Schedule or change my VA appointments		Checkbox, one-up vertical	Multi	N		Additional Services
				Track the status of my prescription refill delivery
				View/pay my VA bills/copayments
				View a list of my VA health care providers and their contact information
				Use a mobile app for My HealtheVet
				Join an online forum to discuss health issues with other Veterans
				Advance check-in for my VA clinic visits
				Authorize sharing information I have stored in My HealtheVet with other people (e.g., family, caregiver)
				Authorize sharing information that I have stored in My HealtheVet with my VA health care team
				Authorize sharing information that I have stored in My HealtheVet with my Non-VA health care provider
				Check to determine if my different medications are safe when taken together
				More online educational programs
				Receive a monthly email newsletter
				Receive notification of new content/features on the site
				Other
ALM0173		What is the main improvement that you would suggest for the My HealtheVet web site?				Text area, no char limit		N		ENDRequest
AED06379		Have you completed this survey within the past 3 months?		Yes		Radio button, one-up vertical				Survey
				No			Single	N
				Don't recall

---

Sheet 7: Current Custom Qsts (1-22-14)

Model Instance Name: VA - My HealtheVet			red & strike-through: DELETE
MID:	NJxFtMU9UosBkJZRd48x9Q==		underlined & italicized: RE-ORDER
			pink: ADDITION
Date:	6/23/2009		blue + -->: REWORDING
20140110 - MHV Meaningful Use Wave 2 l Custom Questions.xlsx			violet (bold): SKIP-LOGIC	As programmed wave 2 Jan
MID: CUSTOM QUESTION LIST
QID	Skip Logic Label	Question Text	Answer Choices (limited to 50 characters)	Skip to	Type (select from list)	Single or Multi	Required Y/N	Special Instructions	Question Label
ALM0170		Which of the following best describes you?	Active duty		Checkbox, one-up vertical	Multi	Y		ANRole
			National Guard/Reserve
			Veteran
			Family member of a veteran or Servicemember
			Caregiver of a Veteran or Servicemember (other than family)
			Veteran Service Organization member
			VA employee
			Non-VA federal government employee
			State/local government employee
			General public
			Other role
RJB00048		Please indicate your military period(s) of service:	Global War on Terror (OEF/OIF/OND)		Checkbox, one-up vertical	Multi	N		ANMilServ
			Desert Shield/Desert Storm
			Vietnam War
			Korean War
			World War II
			Peacetime Service
			Other
		Mutually exclusive	Not Applicable
AED02714		What is your age range?	Under 20		Dropdown (Select-one)	Single	N		ANAge
			20-24
			25-29
			30-34
			35-39
			40-44
			45-49
			50-54
			55-59
			60-64
			65-69
			70-74
			75-79
			80-84
			85 or older
JIC00267		What is your gender?	Male		Dropdown (Select-one)	Single	N		ANGender
			Female
CAS0042785		Are you of Hispanic or Latino origin or descent?	Yes		Drop down, select one	Single	N		ANEthnicity
			No
CAS0042786		What is your race?	American Indian or Alaska Native		Drop down, select one	Single	N		ANRace
			Asian
			Black or African American
			Native Hawaiian or Other Pacific Islander
			White (Caucasian)
			Two or More Races
			Other race
			Unknown or Do Not Wish to Reply
CAS0028939		Which of the following best describes the highest level of education you have completed?	Did not complete high school		Radio button, one-up vertical	Single	Y		ANEduc
			High school graduate
			Some college or vocational school
			College graduate
			Some postgraduate school
			Graduate or professional degree
JIC00178		In general, how would you rate your overall health?	Excellent		Drop down, select one	Single	Y		ANHealth
			Very Good
			Good
			Fair
			Poor
RJB00026		Are you a registered user on the MyHealtheVet web site?	Yes	A	Checkbox, one-up vertical	Single	Y	Skip Logic	ANRegUser
			No
			Not sure
CAS0028940	A	Your member log-in box now includes an icon for your account type. What type of My HealtheVet account do you have?	Basic (B)		Checkbox, one-up vertical	Single	Y	Skip Logic	ANUserType
			Advanced (A)
			Premium (authenticated or IPA’d)(P)
			Not sure
ALM0169		How frequently do you visit the My HealtheVet web site?	First time		Dropdown (Select-one)	Single	Y		ANMHVFreq
			Daily or more than once a day
			About once a week
			About once a month
			About every 6 months
			Less than every 6 months
			Not sure/Do not recall
RJB00022		What were you trying to accomplish today in My HealtheVet? (please select all that apply)			Checkbox, one-up vertical	Multi	Y		ANReason
			Learn more about features that are available
			Request a prescription refill
			View my medication history
			Use Secure Messaging to communicate with my VA health care team
			Use the Blue Button (Download My Data)
			View my VA Appointments
			Look up information about a health condition or medication
			View my lab or other test results
			View my VA Wellness Reminders
			View my VA Notes (written by my health care team)
			Enter my personal information (emergency contacts, etc.)
			Enter data that I track myself such as weight, blood pressure, blood sugar, etc.
			Enter information about my non-VA medications or supplements
			Find a VA facility
			Find information about VA Health Benefits
			Find information about VA Benefits other than health benefits
			Other
ALM0172		Did you accomplish what you wanted to in My HealtheVet?	Yes		Dropdown (Select-one)	Single	Y		ANTaskAcc
			No
			Partially
			Not finished yet
CAS0028943		Do you get care at a VA facility?	Yes	A,B, C, D, E, F	Checkbox, one-up vertical	Single	Y	Skip Logic	ANFacilCare
			No
			Not Sure
CAS0028944	A	In the past year, how often did you use a VA medical facility or service for your health care needs?	Never		Checkbox, one-up vertical	Single	N	skip logic	ANFacilFreq
			Once in the past year
			2 to 11 times in the past year
			12 or more times in the past year
CAS0042864	B	What is your travel time to the VA facility where you receive most of your care?	less than 30 minutes		Radio button, one-up vertical	Single	Y	skip logic	ANDist
			30 minutes to under 1 hour
			1 hour to under 1.5 hours
			1.5 hours to under 2 hours
			2 or more hours
			Not sure/Do not recall
CAS0042867	C	How many years have you been seeing your VA primary healthcare team?	Less than 1 year		Drop down, select one	Single	Y		ANYrsTeam
			1-5 years
			More than 5 years
			Not sure/Do not recall
CAS0042868	D	Generally speaking, how satisfied are you with the quality of care and treatment that you receive from your VA healthcare team?	Very unsatisfied		Radio button, one-up vertical	Single	Y		ANSatTeam
			Unsatisfied
			Neither satisfied nor unsatisfied
			Satisfied
			Very satisfied
			Not sure/Do not recall
CAS0042869	E	Overall, I trust my VA healthcare team's advice and care.	Strongly disagree		Radio button, one-up vertical	Single	Y		ANTrustTeam
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do not recall
CAS0042814	F	Has your VA doctor or healthcare team ever recommended Secure Messaging to you?	Yes		Radio button, one-up vertical	Single	Y		PREverUsed
			No
			Not Sure/Do Not Recall
NEW MEANINGFUL USE Wave 2 QUESTION ROTATION
[ORIENTING QUESTION]:
CAS0046942		Which of the following convinced you to first try My HealtheVet? (Please select all that apply)	My doctor uses it		Checkbox, one-up vertical	Multi	Y		PRTrial
			My doctor recommended it to me
			Someone on my VA healthcare team other than my doctor recommended it to me.
			Another Veteran recommended it to me
			I received a hands-on demonstration at the VA facility.
			I saw a video program or a poster at the VA facility.
			I read a printed fact sheet.
			I received a postcard.
			I received an email reminder.
			I received a phone call from the VA.
			I read or heard about it through the media (newspaper, radio, TV, or social media like Facebook or Twitter).
			I received or saw information materials provided in Spanish.
			Other
			Not sure/Do Not Recall
CAS0046943		How long have you been using My HealtheVet?	Less than 6 months		Radio button, one-up vertical	Single	Y		PRYrsUse
			6 months - less than 1 year
			1-2 years
			More than 2 years
			Not sure/Do Not Recall
[ORIENTING QUESTION]:
CAS0046944		In the past year, how frequently have you used the Blue Button to access your VA personal health record information?	Never		Radio button, one-up vertical	single	Y		PRTaskFreq1
			1-2 times
			3-9 times
			10 or more times
CAS0046945		In the past year, how frequently have you used Secure Messaging to communicate with your doctor or healthcare team?	Never		Radio button, one-up vertical	single	Y		PRTaskFreq2
			1-2 times
			3-9 times
			10 or more times
CAS0046946		In the past year, how frequently have you used My HealtheVet to check your upcoming VA appointments?	Never		Radio button, one-up vertical	single	Y		PRTaskFreq3
			1-2 times
			3-9 times
			10 or more times
CAS0046947		In the past year, how frequently have you used My HealtheVet to request a prescription refill?	Never		Radio button, one-up vertical	single	Y		PRTaskFreq4
			1-2 times
			3-9 times
			10 or more times
CAS0046948		In the past year, how frequently have you used My HealtheVet to check your VA prescription history?	Never		Radio button, one-up vertical	Multi	Y		PRMedFreq5
			1-2 times
			3-9 times
			10 or more times
CAS0046949		In the past year, how frequently have you used My HealtheVet Blue Button to check your VA Notes (the visit notes written by your VA healthcare team)?	Never		Radio button, one-up vertical	single	Y		PRTaskFreq6
			1-2 times
			3-9 times
			10 or more times
CAS0046950		In the past year, how frequently have you used My HealtheVet to check on your lab or test results (for example: blood tests, pathology reports, radiology reports, etc.)?	Never		Radio button, one-up vertical	single	Y		PRTaskFreq7
			1-2 times
			3-9 times
			10 or more times
CAS0046951		In the past year, how frequently have you used My HealtheVet to check your vitals and readings?	Never		Radio button, one-up vertical	single	Y		PRTaskFreq8
			1-2 times
			3-9 times
			10 or more times
CAS0046952		In the past year, how frequently have you used My HealtheVet to check your health summary using the VA Continuity of Care Document (VA CCD)?	Never		Radio button, one-up vertical	single	Y		PRTaskFreq9
			1-2 times
			3-9 times
			10 or more times
CAS0046953		In the past year, which of the following other types of information have you accessed in My HealtheVet or the VA Blue Button? (Please select all that apply)			Radio button, one-up vertical	Multi	Y		PROTaskFreq
			VA Allergies and Adverse Reactions
			VA Immunizations
			VA Problem List (active health issues and conditions)
			VA Admissions and Discharges
			VA Wellness Reminders (for example: shots, cancer screening)
			Department of Defense (DoD) Military Service Information
			None of the above
[ORIENTING QUESTION]:
CAS0046954		In the past year, how frequently have you used My HealtheVet to self-enter your medications and supplements?	Never		Radio button, one-up vertical	single	Y		PRSEFreq1
			1-2 times
			3-9 times
			10 or more times
CAS0046955		In the past year, how frequently have you used My HealtheVet to self-enter your lab and test results labs and tests?	Never		Radio button, one-up vertical	single	Y		PRSEFreq2
			1-2 times
			3-9 times
			10 or more times
CAS0046956		In the past year, how frequently have you used My HealtheVet to self-enter your allergies and adverse reactions?	Never		Radio button, one-up vertical	single	Y		PRSEFreq3
			1-2 times
			3-9 times
			10 or more times
CAS0046957		In the past year, how frequently have you used My HealtheVet to self-enter your vitals and readings?	Never		Radio button, one-up vertical	single	Y		PRSEFreq4
			1-2 times
			3-9 times
			10 or more times
CAS0046958		In the past year, how frequently have you used My HealtheVet to self-enter information in your food journal?	Never		Radio button, one-up vertical	single	Y		PRSEFreq5
			1-2 times
			3-9 times
			10 or more times
CAS0046959		In the past year, how frequently have you used My HealtheVet to self-enter information in your activity journal?	Never		Radio button, one-up vertical	single	Y		PRSEFreq6
			1-2 times
			3-9 times
			10 or more times
CAS0046924		In the past year, how frequently have you used the My Goals feature in My HealtheVet to self-enter your health goals?	Never		Radio button, one-up vertical	single	Y		PRSEFreq7
			1-2 times
			3-9 times
			10 or more times
CAS0046925		In the past year, which other types of information have you self-entered into your My HealtheVet personal health record? (Please select all that apply)			Radio button, one-up vertical	Multi	Y		PRSEOFreq
			Immunizations, self-reported
			Medical events, self-reported
			Family health history, self-reported
			Military health history, self-reported
			Treatment facility, self-reported
			Health insurance, self-reported
			Caregiver names and contacts, self-reported
			Health calendar, self-reported
			Personal information (contact information, emergency contacts), self-reported
			None of the above
[ORIENTING QUESTION]:
CAS0046926		In the past year, how frequently have you communicated with your VA primary healthcare team about information that you self-entered into My HealtheVet? (for example: your home blood glucose or blood pressure measurements)	Never		Radio button, one-up vertical		Y		PRVASelfFreq
			1-2 times
			3-9 times
			10 or more times
CAS0046927		In the past year, how frequently have you communicated with your VA primary healthcare team about information that you accessed from your VA medical record in My HealtheVet? (for example: your VA Notes)	Never		Radio button, one-up vertical		Y		PRVAMHVFreq
			1-2 times
			3-9 times
			10 or more times
CAS0046928		In the past year, how frequently have you communicated with your other VA healthcare providers (for example: your specialist physicians, therapists, counselors and coordinators) about information that you self-entered into My HealtheVet?	Never		Radio button, one-up vertical		Y		PROtherSelfFreq
			1-2 times
			3-9 times
			10 or more times
CAS0046962		In the past year, how frequently have you communicated with your other VA healthcare providers (for example: your specialist physicians, therapists, counselors and coordinators) about information that you accessed from your VA medical record in My HealtheVet? (for example: your VA Notes)	Never		Radio button, one-up vertical		Y		PROtherMHVFreq
			1-2 times
			3-9 times
			10 or more times
CAS0046963		In the past year, how frequently have you used My HealtheVet information when you communicated with your VA healthcare team about care you received outside of the VA? (for example: tests done elsewhere or a non-VA emergency department visit)	Never		Radio button, one-up vertical	single	Y		PROutsideCare
			1-2 times
			3-9 times
			10 or more times
CAS0046964		In the past year, how frequently have you used My HealtheVet information when you communicated with your non-VA providers about care you received at the VA?	Never		Radio button, one-up vertical	single	Y		PRNonVAProvider
			1-2 times
			3-9 times
			10 or more times
			I do not have any non-VA providers
CAS0046964		Which of the following methods do you use to access the My HealtheVet website? (Please select all that apply)	Computer or laptop		Checkbox, one-up vertical	Multi	Y		PRDevice
			Mobile phone (for example: iPhone, Android)
			Mobile tablet (for example: iPad, Android)
			Kiosk
			Television (for example: interactive Web TV )
			Other
[ORIENTING INTRODUCTION]		Your feedback is very important to us. Please think about your use of My HealtheVet features other than Secure Messaging when answering the following questions.
CAS0046966		The information in My HealtheVet is accurate.	Strongly disagree		Radio button, one-up vertical	Single	Y		PRAccurate
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do Not Recall
CAS0046967		The information in My HealtheVet is easy to understand.	Strongly disagree		Radio button, one-up vertical	Single	Y		PREasy
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do Not Recall
CAS0046968		New or updated information in My HealtheVet is generally available to me in a timely manner.	Strongly disagree		Radio button, one-up vertical	Single	Y		PRTimely
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do Not Recall
CAS0046969		My HealtheVet is a reliable system. (That is, I can always count on it working.)	Strongly disagree		Radio button, one-up vertical	Single	Y		PRProtect
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do Not Recall
CAS0046970		I am confident that My HealtheVet protects the privacy and security of my personal health information.	Strongly disagree		Radio button, one-up vertical	Single	Y		PRPrivate
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do Not Recall
CAS0046971		It is easy to find the different My HealtheVet features that I want to use.	Strongly disagree		Radio button, one-up vertical	Single	Y		PRONavToSM
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do Not Recall
CAS0046972		It is easy to navigate within the My HealtheVet features (for example, checking my VA Prescription status then requesting a refill).	Strongly disagree		Radio button, one-up vertical	Single	Y		PRNavInSM
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do Not Recall
CAS0046973		I trust my healthcare information when I receive it through My HealtheVet.	Strongly disagree		Radio button, one-up vertical	Single	Y		PRTrustOnline
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do Not Recall
CAS0046974		Regarding my personal health goals, I use My HealtheVet to help me: (Please select all that apply)			Checkbox, one-up vertical	Multi	Y		PRGoals
			Self-enter and track my personal health goals
			Gain peace of mind about my personal health goals
			Coordinate with my VA healthcare team based on my personal health goals
			None of the above
CAS0046975		Regarding my VA medications, I use My HealtheVet to help me: (Please select all that apply)			Checkbox, one-up vertical	Multi	Y		PRMeds
			Review and understand my VA-prescribed medications
			Gain peace of mind about my VA-prescribed medications
			Coordinate with my VA healthcare team about my VA-prescribed medications
			None of the above
CAS0046929		Regarding my VA tests and procedures, I use My HealtheVet to help me: (Please select all that apply)			Checkbox, one-up vertical	Multi	Y		PRTestPRoc
			Review and understand the tests and procedures that I receive from VA
			Gain peace of mind from my VA healthcare team about tests and procedures that I receive from VA
			Coordinate with my VA healthcare team about the tests and procedures that I receive from VA
			None of the above
CAS0046930		Regarding my mental and emotional health, I use My HealtheVet to help me: (Please select all that apply)			Checkbox, one-up vertical	Multi	Y		PRMentalHealth
			Review and understand my mental and emotional health and any prescribed treatment
			Gain peace of mind about my mental and emotional health and any prescribed treatment
			Coordinate with my VA healthcare team about my mental and emotional health and any prescribed treatment
			None of the above
CAS0046931		Regarding my VA preventive care (for example: screenings for type 2 diabetes, cholesterol, depression), I use My HealtheVet to help me: (Please select all that apply)			Checkbox, one-up vertical	Multi	Y		PRPreventive
			Review and understand my VA preventive care
			Gain peace of mind about my VA preventive care
			Coordinate with my VA healthcare team about my VA preventive care
			None of the above
CAS0046932		Regarding things I can do for my health (such as diet and exercise), I use My HealtheVet to help me: (Please select all that apply)	Review and understand specific things I can do to improve my health or prevent illness		Checkbox, one-up vertical	Multi	Y		PRSelfCare
			Self-enter and track specific things I can do to improve my health or prevent illness
			Gain peace of mind about specific things I can do to improve my health or prevent illness
			Coordinate with my VA healthcare team about specific things I can do to improve my health or prevent illness
			None of the above
CAS0046933		After treatment, labs or tests, I review my results on My HealtheVet to see if I need a follow-up call or visit.	Strongly disagree		Radio button, one-up vertical	Single	Y		PRFollowUp
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
CAS0046934		I use My HealtheVet information to help me make better health and healthcare decisions.	Strongly disagree		Radio button, one-up vertical	Single	Y		PRDecisInfo
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
CAS0046935		I use My HealtheVet to help me judge when it is necessary to call or go see my VA healthcare team.	Strongly disagree		Radio button, one-up vertical	Single	Y		PRDecisCall
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
CAS0046936		I use My HealtheVet to help me figure out solutions when new problems arise with my health.	Strongly disagree		Radio button, one-up vertical	Single	Y		PRSolutions
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
CAS0046937		I have all the information I need to manage my health and healthcare.	Strongly disagree		Radio button, one-up vertical	Single	Y		OUTInfo
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
CAS0046938		I am confident in working with my VA healthcare team to manage my health and healthcare.	Strongly disagree		Radio button, one-up vertical	Single	Y		OUTTeam
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
CAS0046939		I feel in control of my health and healthcare (such as taking part in decisions or following through on any medication, treatment or health routine).	Strongly disagree		Radio button, one-up vertical	Single	Y		OUTControl
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
CAS0046940		I am able to achieve my long-term health and healthcare goals (such as being self-reliant, living longer and better, or knowing that my family and friends can depend on me.)	Strongly disagree		Radio button, one-up vertical	Single	Y		OUTAchGoals
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
CAS0046941		I intend to continue using My HealtheVet in the future.	Strongly disagree		Radio button, one-up vertical	Single	Y		OUTIntentUse
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
CAS0046982		I intend to recommend My HealtheVet to others.	Strongly disagree		Radio button, one-up vertical	Single	Y		OUTIntentRec
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
CAS0042904		How often do you find that information from the VA (in print or online) about your medical condition is difficult to understand?	Never or almost never		Radio button, one-up vertical	Single	Y		ANHlthLit
			Infrequently
			Occasionally
			Frequently
			Very frequently or always
			Not sure/Do not recall
RJB00029		My use of the My HealtheVet personal health record has improved my ability to manage my health.	Strongly disagree		Radio button, one-up vertical	Single	Y		MHV improve Health
			Disagree
			Not sure
			Disagree
			Agree
			Strongly agree
			Not applicable
CAS0042905		Overall, how confident are you that you could get health-related advice or information if you needed it by using a computer, smart phone or tablet (like an iPhone or iPad)?	Not at all confident		Radio button, one-up vertical	Single	Y		ANHlthSearch
			Somewhat confident
			Moderately confident
			Confident
			Very confident
			Not sure
CAS0029040		What additional services would you like to see on My HealtheVet? (Please select all that apply)	Schedule or change my VA appointments		Checkbox, one-up vertical	Multi	N		Additional Services
			Track the status of my prescription refill delivery
			View/pay my VA bills/copayments
			View a list of my VA health care providers and their contact information
			Use a mobile app for My HealtheVet
			Join an online forum to discuss health issues with other Veterans
			Advance check-in for my VA clinic visits
			Authorize sharing information I have stored in My HealtheVet with other people (e.g., family, caregiver)
			Authorize sharing information that I have stored in My HealtheVet with my VA health care team
			Authorize sharing information that I have stored in My HealtheVet with my Non-VA health care provider
			Check to determine if my different medications are safe when taken together
			More online educational programs
			Receive a monthly email newsletter
			Receive notification of new content/features on the site
			Other
ALM0173		What is the main improvement that you would suggest for the My HealtheVet web site?			Text area, no char limit		N		ENDRequest
AED06379		Have you completed this survey within the past 3 months?	Yes		Radio button, one-up vertical				Survey
			No			Single	N
			Don't recall

---

Sheet 8: Current Custom Qsts (1-17-14)

Model Instance Name: VA - My HealtheVet			red & strike-through: DELETE
MID:	NJxFtMU9UosBkJZRd48x9Q==		underlined & italicized: RE-ORDER
			pink: ADDITION
Date:	6/23/2009		blue + -->: REWORDING
20140110 - MHV Meaningful Use Wave 2 l Custom Questions.xlsx			violet (bold): SKIP-LOGIC	As programmed wave 2 Jan
MID: CUSTOM QUESTION LIST
QID	Skip Logic Label	Question Text	Answer Choices (limited to 50 characters)	Skip to	Type (select from list)	Single or Multi	Required Y/N	Special Instructions	Question Label
ALM0170		Which of the following best describes you?	Active duty		Checkbox, one-up vertical	Multi	Y		ANRole
			National Guard/Reserve
			Veteran
			Family member of a veteran or Servicemember
			Caregiver of a Veteran or Servicemember (other than family)
			Veteran Service Organization member
			VA employee
			Non-VA federal government employee
			State/local government employee
			General public
			Other role
RJB00048		Please indicate your military period(s) of service:	Global War on Terror (OEF/OIF/OND)		Checkbox, one-up vertical	Multi	N		ANMilServ
			Desert Shield/Desert Storm
			Vietnam War
			Korean War
			World War II
			Peacetime Service
			Other
		Mutually exclusive	Not Applicable
AED02714		What is your age range?	Under 20		Dropdown (Select-one)	Single	N		ANAge
			20-24
			25-29
			30-34
			35-39
			40-44
			45-49
			50-54
			55-59
			60-64
			65-69
			70-74
			75-79
			80-84
			85 or older
JIC00267		What is your gender?	Male		Dropdown (Select-one)	Single	N		ANGender
			Female
CAS0042785		Are you of Hispanic or Latino origin or descent?	Yes		Drop down, select one	Single	N		ANEthnicity
			No
CAS0042786		What is your race?	American Indian or Alaska Native		Drop down, select one	Single	N		ANRace
			Asian
			Black or African American
			Native Hawaiian or Other Pacific Islander
			White (Caucasian)
			Two or More Races
			Other race
			Unknown or Do Not Wish to Reply
CAS0028939		Which of the following best describes the highest level of education you have completed?	Did not complete high school		Radio button, one-up vertical	Single	Y		ANEduc
			High school graduate
			Some college or vocational school
			College graduate
			Some postgraduate school
			Graduate or professional degree
JIC00178		In general, how would you rate your overall health?	Excellent		Drop down, select one	Single	Y		ANHealth
			Very Good
			Good
			Fair
			Poor
RJB00026		Are you a registered user on the MyHealtheVet web site?	Yes	A	Checkbox, one-up vertical	Single	Y	Skip Logic	ANRegUser
			No
			Not sure
CAS0028940	A	Your member log-in box now includes an icon for your account type. What type of My HealtheVet account do you have?	Basic (B)		Checkbox, one-up vertical	Single	Y	Skip Logic	ANUserType
			Advanced (A)
			Premium (authenticated or IPA’d)(P)
			Not sure
ALM0169		How frequently do you visit the My HealtheVet web site?	First time		Dropdown (Select-one)	Single	Y		ANMHVFreq
			Daily or more than once a day
			About once a week
			About once a month
			About every 6 months
			Less than every 6 months
			Not sure/Do not recall
RJB00022		What were you trying to accomplish today in My HealtheVet? (please select all that apply)			Checkbox, one-up vertical	Multi	Y		ANReason
			Learn more about features that are available
			Request a prescription refill
			View my medication history
			Use Secure Messaging to communicate with my VA health care team
			Use the Blue Button (Download My Data)
			View my VA Appointments
			Look up information about a health condition or medication
			View my lab or other test results
			View my VA Wellness Reminders
			View my VA Notes (written by my health care team)
			Enter my personal information (emergency contacts, etc.)
			Enter data that I track myself such as weight, blood pressure, blood sugar, etc.
			Enter information about my non-VA medications or supplements
			Find a VA facility
			Find information about VA Health Benefits
			Find information about VA Benefits other than health benefits
			Other
ALM0172		Did you accomplish what you wanted to in My HealtheVet?	Yes		Dropdown (Select-one)	Single	Y		ANTaskAcc
			No
			Partially
			Not finished yet
CAS0028943		Do you get care at a VA facility?	Yes	A,B, C, D, E, F	Checkbox, one-up vertical	Single	Y	Skip Logic	ANFacilCare
			No
			Not Sure
CAS0028944	A	In the past year, how often did you use a VA medical facility or service for your health care needs?	Never		Checkbox, one-up vertical	Single	N	skip logic	ANFacilFreq
			Once in the past year
			2 to 11 times in the past year
			12 or more times in the past year
CAS0042864	B	What is your travel time to the VA facility where you receive most of your care?	less than 30 minutes		Radio button, one-up vertical	Single	Y	skip logic	ANDist
			30 minutes to under 1 hour
			1 hour to under 1.5 hours
			1.5 hours to under 2 hours
			2 or more hours
			Not sure/Do not recall
CAS0042867	C	How many years have you been seeing your VA primary healthcare team?	Less than 1 year		Drop down, select one	Single	Y		ANYrsTeam
			1-5 years
			More than 5 years
			Not sure/Do not recall
CAS0042868	D	Generally speaking, how satisfied are you with the quality of care and treatment that you receive from your VA healthcare team?	Very unsatisfied		Radio button, one-up vertical	Single	Y		ANSatTeam
			Unsatisfied
			Neither satisfied nor unsatisfied
			Satisfied
			Very satisfied
			Not sure/Do not recall
CAS0042869	E	Overall, I trust my VA healthcare team's advice and care.	Strongly disagree		Radio button, one-up vertical	Single	Y		ANTrustTeam
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do not recall
CAS0042814	F	Has your VA doctor or healthcare team ever recommended Secure Messaging to you?	Yes		Radio button, one-up vertical	Single	Y		PREverUsed
			No
			Not Sure/Do Not Recall
NEW MEANINGFUL USE Wave 2 QUESTION ROTATION
[ORIENTING QUESTION]:
CAS0046942		Which of the following convinced you to first try My HealtheVet? (Please select all that apply)	My doctor uses it		Checkbox, one-up vertical	Multi	Y		PRTrial
			My doctor recommended it to me
			Someone on my VA healthcare team other than my doctor recommended it to me.
			Another Veteran recommended it to me
			I received a hands-on demonstration at the VA facility.
			I saw a video program or a poster at the VA facility.
			I read a printed fact sheet.
			I received a postcard.
			I received an email reminder.
			I received a phone call from the VA.
			I read or heard about it through the media (newspaper, radio, TV, or social media like Facebook or Twitter).
			I received or saw information materials provided in Spanish.
			Other
			Not sure/Do Not Recall
CAS0046943		How long have you been using My HealtheVet?	Less than 6 months		Radio button, one-up vertical	Single	Y		PRYrsUse
			6 months - less than 1 year
			1-2 years
			More than 2 years
			Not sure/Do Not Recall
[ORIENTING QUESTION]:
CAS0046944		In the past year, how frequently have you used the Blue Button to access your VA personal health record information?	Never		Radio button, one-up vertical	single	Y		PRTaskFreq1
			1-2 times
			3-9 times
			10 or more times
CAS0046945		In the past year, how frequently have you used Secure Messaging to communicate with your doctor or healthcare team?	Never		Radio button, one-up vertical	single	Y		PRTaskFreq2
			1-2 times
			3-9 times
			10 or more times
CAS0046946		In the past year, how frequently have you used My HealtheVet to check your upcoming VA appointments?	Never		Radio button, one-up vertical	single	Y		PRTaskFreq3
			1-2 times
			3-9 times
			10 or more times
CAS0046947		In the past year, how frequently have you used My HealtheVet to request a prescription refill?	Never		Radio button, one-up vertical	single	Y		PRTaskFreq4
			1-2 times
			3-9 times
			10 or more times
CAS0046948		In the past year, how frequently have you used My HealtheVet to check your VA prescription history?	Never		Radio button, one-up vertical	Multi	Y		PRMedFreq5
			1-2 times
			3-9 times
			10 or more times
CAS0046949		In the past year, how frequently have you used My HealtheVet Blue Button to check your VA Notes (the visit notes written by your VA healthcare team)?	Never		Radio button, one-up vertical	single	Y		PRTaskFreq6
			1-2 times
			3-9 times
			10 or more times
CAS0046950		In the past year, how frequently have you used My HealtheVet to check on your lab or test results (for example: blood tests, pathology reports, radiology reports, etc.)?	Never		Radio button, one-up vertical	single	Y		PRTaskFreq7
			1-2 times
			3-9 times
			10 or more times
CAS0046951		In the past year, how frequently have you used My HealtheVet to check your vitals and readings?	Never		Radio button, one-up vertical	single	Y		PRTaskFreq8
			1-2 times
			3-9 times
			10 or more times
CAS0046952		In the past year, how frequently have you used My HealtheVet to check your health summary using the VA Continuity of Care Document (VA CCD)?	Never		Radio button, one-up vertical	single	Y		PRTaskFreq9
			1-2 times
			3-9 times
			10 or more times
CAS0046953		In the past year, which of the following other types of information have you accessed in My HealtheVet or the VA Blue Button? (Please select all that apply)			Radio button, one-up vertical	Multi	Y		PROTaskFreq
			VA Allergies and Adverse Reactions
			VA Immunizations
			VA Problem List (active health issues and conditions)
			VA Admissions and Discharges
			VA Wellness Reminders (for example: shots, cancer screening)
			Department of Defense (DoD) Military Service Information
			None of the above
[ORIENTING QUESTION]:
CAS0046954		In the past year, how frequently have you used My HealtheVet to self-enter your medications and supplements?	Never		Radio button, one-up vertical	single	Y		PRSEFreq1
			1-2 times
			3-9 times
			10 or more times
CAS0046955		In the past year, how frequently have you used My HealtheVet to self-enter your labs and tests?	Never		Radio button, one-up vertical	single	Y		PRSEFreq2
			1-2 times
			3-9 times
			10 or more times
CAS0046956		In the past year, how frequently have you used My HealtheVet to self-enter your allergies and adverse reactions?	Never		Radio button, one-up vertical	single	Y		PRSEFreq3
			1-2 times
			3-9 times
			10 or more times
CAS0046957		In the past year, how frequently have you used My HealtheVet to self-enter your vitals and readings?	Never		Radio button, one-up vertical	single	Y		PRSEFreq4
			1-2 times
			3-9 times
			10 or more times
CAS0046958		In the past year, how frequently have you used My HealtheVet to self-enter information in your food journal?	Never		Radio button, one-up vertical	single	Y		PRSEFreq5
			1-2 times
			3-9 times
			10 or more times
CAS0046959		In the past year, how frequently have you used My HealtheVet to self-enter information in your activity journal?	Never		Radio button, one-up vertical	single	Y		PRSEFreq6
			1-2 times
			3-9 times
			10 or more times
CAS0046924		In the past year, how frequently have you used the My Goals feature in My HealtheVet to self-enter your health goals?	Never		Radio button, one-up vertical	single	Y		PRSEFreq7
			1-2 times
			3-9 times
			10 or more times
CAS0046925		In the past year, which other types of information have you self-entered into your My HealtheVet personal health record? (Please select all that apply)			Radio button, one-up vertical	Multi	Y		PRSEOFreq
			Immunizations, self-reported
			Medical events, self-reported
			Family health history, self-reported
			Military health history, self-reported
			Treatment facility, self-reported
			Health insurance, self-reported
			Caregiver names and contacts, self-reported
			Health calendar, self-reported
			Personal information (contact information, emergency contacts), self-reported
			None of the above
[ORIENTING QUESTION]:
CAS0046926		In the past year, how frequently have you communicated with your VA primary healthcare team about information that you self-entered into My HealtheVet? (for example: your home blood glucose or blood pressure measurements)	Never		Radio button, one-up vertical		Y		PRVASelfFreq
			1-2 times
			3-9 times
			10 or more times
CAS0046927		In the past year, how frequently have you communicated with your VA primary healthcare team about information that you accessed from your VA medical record in My HealtheVet? (for example: your VA Notes)	Never		Radio button, one-up vertical		Y		PRVAMHVFreq
			1-2 times
			3-9 times
			10 or more times
CAS0046928		In the past year, how frequently have you communicated with your other VA healthcare providers (for example: your specialist physicians, therapists, counselors and coordinators) about information that you self-entered into My HealtheVet?	Never		Radio button, one-up vertical		Y		PROtherSelfFreq
			1-2 times
			3-9 times
			10 or more times
CAS0046962		In the past year, how frequently have you communicated with your other VA healthcare providers (for example: your specialist physicians, therapists, counselors and coordinators) about information that you accessed from your VA medical record in My HealtheVet? (for example: your VA Notes)	Never		Radio button, one-up vertical		Y		PROtherMHVFreq
			1-2 times
			3-9 times
			10 or more times
CAS0046963		In the past year, how frequently have you used My HealtheVet information when you communicated with your VA healthcare team about care you received outside of the VA? (for example: tests done elsewhere or a non-VA emergency department visit)	Never		Radio button, one-up vertical	single	Y		PROutsideCare
			1-2 times
			3-9 times
			10 or more times
CAS0046964		In the past year, how frequently have you used My HealtheVet information when you communicated with your non-VA providers about care you received at the VA?	Never		Radio button, one-up vertical	single	Y		PRNonVAProvider
			1-2 times
			3-9 times
			10 or more times
CAS0046964		Which of the following methods do you use to access the My HealtheVet website? (Please select all that apply)	Computer or laptop		Checkbox, one-up vertical	Multi	Y		PRDevice
			Mobile phone (for example: iPhone, Android)
			Mobile tablet (for example: iPad, Android)
			Kiosk
			Television (for example: interactive Web TV )
			Other
[ORIENTING INTRODUCTION]		Your feedback is very important to us. Please think about your use of My HealtheVet features other than Secure Messaging when answering the following questions.
CAS0046966		The information in My HealtheVet is accurate.	Strongly disagree		Radio button, one-up vertical	Single	Y		PRAccurate
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do Not Recall
CAS0046967		The information in My HealtheVet is easy to understand.	Strongly disagree		Radio button, one-up vertical	Single	Y		PREasy
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do Not Recall
CAS0046968		New or updated information in My HealtheVet is generally available to me in a timely manner.	Strongly disagree		Radio button, one-up vertical	Single	Y		PRTimely
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do Not Recall
CAS0046969		My HealtheVet is a reliable system. (That is, I can always count on it working.)	Strongly disagree		Radio button, one-up vertical	Single	Y		PRProtect
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do Not Recall
CAS0046970		I am confident that My HealtheVet protects the privacy and security of my personal health information.	Strongly disagree		Radio button, one-up vertical	Single	Y		PRPrivate
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do Not Recall
CAS0046971		It is easy to find the different My HealtheVet features that I want to use.	Strongly disagree		Radio button, one-up vertical	Single	Y		PRONavToSM
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do Not Recall
CAS0046972		It is easy to navigate within the My HealtheVet features (for example, checking my VA Prescription status then requesting a refill).	Strongly disagree		Radio button, one-up vertical	Single	Y		PRNavInSM
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do Not Recall
CAS0046973		I trust my healthcare information when I receive it through My HealtheVet.	Strongly disagree		Radio button, one-up vertical	Single	Y		PRTrustOnline
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do Not Recall
CAS0046974		Regarding my personal health goals, I use My HealtheVet to help me: (Please select all that apply)			Checkbox, one-up vertical	Multi	Y		PRGoals
			Self-enter and track my personal health goals
			Gain peace of mind about my personal health goals
			Coordinate with my VA healthcare team based on my personal health goals
			Not sure/Do Not Recall __>None of the above
CAS0046975		Regarding my VA medications, I use My HealtheVet to help me: (Please select all that apply)			Checkbox, one-up vertical	Multi	Y		PRMeds
			Review and understand my VA-prescribed medications
			Gain peace of mind about my VA-prescribed medications
			Coordinate with my VA healthcare team about my VA-prescribed medications
			None of the above
CAS0046929		Regarding my VA tests and procedures, I use My HealtheVet to help me: (Please select all that apply)			Checkbox, one-up vertical	Multi	Y		PRTestPRoc
			Review and understand the tests and procedures that I receive from VA
			Gain peace of mind from my VA healthcare team about tests and procedures that I receive from VA
			Coordinate with my VA healthcare team about the tests and procedures that I receive from VA
			Not sure/Do Not Recall __>None of the above
CAS0046930		Regarding my mental and emotional health, I use My HealtheVet to help me: (Please select all that apply)			Checkbox, one-up vertical	Multi	Y		PRMentalHealth
			Review and understand my mental and emotional health and any prescribed treatment
			Gain peace of mind about my mental and emotional health and any prescribed treatment
			Coordinate with my VA healthcare team about my mental and emotional health and any prescribed treatment
			Not sure/Do Not Recall __>None of the above
CAS0046931		Regarding my VA preventive care (for example: screenings for type 2 diabetes, cholesterol, depression), I use My HealtheVet to help me: (Please select all that apply)			Checkbox, one-up vertical	Multi	Y		PRPreventive
			Review and understand my VA preventive care
			Gain peace of mind about my VA preventive care
			Coordinate with my VA healthcare team about my VA preventive care
			None of the above
CAS0046932		Regarding things I can do for my health (such as diet and exercise), I use My HealtheVet to help me: (Please select all that apply)	Review and understand specific things I can do to improve my health or prevent illness		Checkbox, one-up vertical	Multi	Y		PRSelfCare
			Self-enter and track specific things I can do to improve my health or prevent illness
			Gain peace of mind about specific things I can do to improve my health or prevent illness
			Coordinate with my VA healthcare team about specific things I can do to improve my health or prevent illness
			None of the above
CAS0046933		After treatment, labs or tests, I review my results on My HealtheVet to see if I need a follow-up call or visit.	Strongly disagree		Radio button, one-up vertical	Single	Y		PRFollowUp
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
CAS0046934		I use My HealtheVet information to help me make better health and healthcare decisions.	Strongly disagree		Radio button, one-up vertical	Single	Y		PRDecisInfo
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
CAS0046935		I use My HealtheVet to help me judge when it is necessary to call or go see my VA healthcare team.	Strongly disagree		Radio button, one-up vertical	Single	Y		PRDecisCall
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
CAS0046936		I use My HealtheVet to help me figure out solutions when new problems arise with my health.	Strongly disagree		Radio button, one-up vertical	Single	Y		PRSolutions
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
CAS0046937		I have all the information I need to manage my health and healthcare.	Strongly disagree		Radio button, one-up vertical	Single	Y		OUTInfo
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
CAS0046938		I am confident in working with my VA healthcare team to manage my health and healthcare.	Strongly disagree		Radio button, one-up vertical	Single	Y		OUTTeam
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
CAS0046939		I feel in control of my health and healthcare (such as taking part in decisions or following through on any medication, treatment or health routine).	Strongly disagree		Radio button, one-up vertical	Single	Y		OUTControl
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
CAS0046940		I am able to achieve my long-term health and healthcare goals (such as being self-reliant, living longer and better, or knowing that my family and friends can depend on me.)	Strongly disagree		Radio button, one-up vertical	Single	Y		OUTAchGoals
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
CAS0046941		I intend to continue using My HealtheVet in the future.	Strongly disagree		Radio button, one-up vertical	Single	Y		OUTIntentUse
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
CAS0046982		I intend to recommend My HealtheVet to others.	Strongly disagree		Radio button, one-up vertical	Single	Y		OUTIntentRec
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
CAS0042904		How often do you find that information from the VA (in print or online) about your medical condition is difficult to understand?	Never or almost never		Radio button, one-up vertical	Single	Y		ANHlthLit
			Infrequently
			Occasionally
			Frequently
			Very frequently or always
			Not sure/Do not recall
RJB00029		My use of the My HealtheVet personal health record has improved my ability to manage my health.	Strongly disagree		Radio button, one-up vertical	Single	Y		MHV improve Health
			Disagree
			Not sure
			Disagree
			Agree
			Strongly agree
			Not applicable
CAS0042905		Overall, how confident are you that you could get health-related advice or information if you needed it by using a computer, smart phone or tablet (like an iPhone or iPad)?	Not at all confident		Radio button, one-up vertical	Single	Y		ANHlthSearch
			Somewhat confident
			Moderately confident
			Confident
			Very confident
			Not sure
CAS0029040		What additional services would you like to see on My HealtheVet? (Please select all that apply)	Schedule or change my VA appointments		Checkbox, one-up vertical	Multi	N		Additional Services
			Track the status of my prescription refill delivery
			View/pay my VA bills/copayments
			View a list of my VA health care providers and their contact information
			Use a mobile app for My HealtheVet
			Join an online forum to discuss health issues with other Veterans
			Advance check-in for my VA clinic visits
			Authorize sharing information I have stored in My HealtheVet with other people (e.g., family, caregiver)
			Authorize sharing information that I have stored in My HealtheVet with my VA health care team
			Authorize sharing information that I have stored in My HealtheVet with my Non-VA health care provider
			Check to determine if my different medications are safe when taken together
			More online educational programs
			Receive a monthly email newsletter
			Receive notification of new content/features on the site
			Other
ALM0173		What is the main improvement that you would suggest for the My HealtheVet web site?			Text area, no char limit		N		ENDRequest
AED06379		Have you completed this survey within the past 3 months?	Yes		Radio button, one-up vertical				Survey
			No			Single	N
			Don't recall

---

Sheet 9: Current Custom Qsts (1-15-14)

Model Instance Name: VA - My HealtheVet			red & strike-through: DELETE
MID:	NJxFtMU9UosBkJZRd48x9Q==		underlined & italicized: RE-ORDER
			pink: ADDITION
Date:	6/23/2009		blue + -->: REWORDING
20140110 - MHV Meaningful Use Wave 2 l Custom Questions.xlsx			violet (bold): SKIP-LOGIC		proposed Wave 2
MID: CUSTOM QUESTION LIST
QID	Skip Logic Label	Question Text	Answer Choices (limited to 50 characters)	Skip to	Type (select from list)	Single or Multi	Required Y/N	Special Instructions	Question Label
ALM0170		Which of the following best describes you?	Active duty		Checkbox, one-up vertical	Multi	Y		ANRole
			National Guard/Reserve
			Veteran
			Family member of a veteran or Servicemember
			Caregiver of a Veteran or Servicemember (other than family)
			Veteran Service Organization member
			VA employee
			Non-VA federal government employee
			State/local government employee
			General public
			Other role
RJB00048		Please indicate your military period(s) of service:	Global War on Terror (OEF/OIF/OND)		Checkbox, one-up vertical	Multi	N		ANMilServ
			Desert Shield/Desert Storm
			Vietnam War
			Korean War
			World War II
			Peacetime Service
			Other
			Not Applicable
AED02714		What is your age range?	Under 20		Dropdown (Select-one)	Single	N		ANAge
			20-24
			25-29
			30-34
			35-39
			40-44
			45-49
			50-54
			55-59
			60-64
			65-69
			70-74
			75-79
			80-84
			85 or older
JIC00267		What is your gender?	Male		Dropdown (Select-one)	Single	N		ANGender
			Female
CAS0042785		Are you of Hispanic or Latino origin or descent?	Yes		Drop down, select one	Single	N		ANEthnicity
			No
CAS0042786		What is your race?	American Indian or Alaska Native		Drop down, select one	Single	N		ANRace
			Asian
			Black or African American
			Native Hawaiian or Other Pacific Islander
			White (Caucasian)
			Two or More Races
			Other race
			Unknown or Do Not Wish to Reply
CAS0028939		Which of the following best describes the highest level of education you have completed?	Did not complete high school		Radio button, one-up vertical	Single	Y		ANEduc
			High school graduate
			Some college or vocational school
			College graduate
			Some postgraduate school
			Graduate or professional degree
JIC00178		In general, how would you rate your overall health?	Excellent		Drop down, select one	Single	Y		ANHealth
			Very Good
			Good
			Fair
			Poor
RJB00026		Are you a registered user on the MyHealtheVet web site?	Yes	A	Checkbox, one-up vertical	Single	Y	Skip Logic	ANRegUser
			No
			Not sure
CAS0028940	A	Your member log-in box now includes an icon for your account type. What type of My HealtheVet account do you have?	Basic (B)		Checkbox, one-up vertical	Single	Y	Skip Logic	ANUserType
			Advanced (A)
			Premium (authenticated or IPA’d)(P)
			Not sure
ALM0169		How frequently do you visit the My HealtheVet web site?	First time		Dropdown (Select-one)	Single	Y		ANMHVFreq
			Daily or more than once a day
			About once a week
			About once a month
			About every 6 months
			Less than every 6 months
			Not sure/Do not recall
RJB00022		What were you trying to accomplish today in My HealtheVet? (please select all that apply)			Checkbox, one-up vertical	Multi	Y		ANReason
			Learn more about features that are available
			Request a prescription refill
			View my medication history
			Use Secure Messaging to communicate with my VA health care team
			Use the Blue Button (Download My Data)
			View my VA Appointments
			Look up information about a health condition or medication
			View my lab or other test results
			View my VA Wellness Reminders
			View my VA Notes (written by my health care team)
			Enter my personal information (emergency contacts, etc.)
			Enter data that I track myself such as weight, blood pressure, blood sugar, etc.
			Enter information about my non-VA medications or supplements
			Find a VA facility
			Find information about VA Health Benefits
			Find information about VA Benefits other than health benefits
			Other
ALM0172		Did you accomplish what you wanted to in My HealtheVet?	Yes		Dropdown (Select-one)	Single	Y		ANTaskAcc
			No
			Partially
			Not finished yet
CAS0028943		Do you get care at a VA facility?	Yes	A,B, C, D, E, F	Checkbox, one-up vertical	Single	Y	Skip Logic	ANFacilCare
			No
			Not Sure
CAS0028944	A	In the past year, how often did you use a VA medical facility or service for your health care needs?	Never		Checkbox, one-up vertical	Single	N	skip logic	ANFacilFreq
			Once in the past year
			2 to 11 times in the past year
			12 or more times in the past year
CAS0042864	B	What is your travel time to the VA facility where you receive most of your care?	less than 30 minutes		Radio button, one-up vertical	Single	Y	skip logic	ANDist
			30 minutes to under 1 hour
			1 hour to under 1.5 hours
			1.5 hours to under 2 hours
			2 or more hours
			Not sure/Do not recall
CAS0042867	C	How many years have you been seeing your VA primary healthcare team?	Less than 1 year		Drop down, select one	Single	Y		ANYrsTeam
			1-5 years
			More than 5 years
			Not sure/Do not recall
CAS0042868	D	Generally speaking, how satisfied are you with the quality of care and treatment that you receive from your VA healthcare team?	Very unsatisfied		Radio button, one-up vertical	Single	Y		ANSatTeam
			Unsatisfied
			Neither satisfied nor unsatisfied
			Satisfied
			Very satisfied
			Not sure/Do not recall
CAS0042869	E	Overall, I trust my VA healthcare team's advice and care.	Strongly disagree		Radio button, one-up vertical	Single	Y		ANTrustTeam
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do not recall
CAS0042814	F	Has your VA doctor or healthcare team ever recommended Secure Messaging to you?	Yes		Radio button, one-up vertical	Single	Y		PREverUsed
			No
			Not Sure/Do Not Recall
NEW MEANINGFUL USE Wave 2 QUESTION ROTATION
[ORIENTING QUESTION]:
		Which of the following convinced you to first try My HealtheVet? (Please select all that apply)	My doctor uses it		Checkbox, one-up vertical	Multi	Y		PRTrial
			My doctor recommended it to me
			Someone on my VA healthcare team other than my doctor recommended it to me.
			Another Veteran recommended it to me
			I received a hands-on demonstration at the VA facility.
			I saw a video program or a poster at the VA facility.
			I read a printed fact sheet.
			I received a postcard.
			I received an email reminder.
			I received a phone call from the VA.
			I read or heard about it through the media (newspaper, radio, TV, or social media like Facebook or Twitter).
			I received or saw information materials provided in Spanish.
			Other
			Not sure/Do Not Recall
		How long have you been using My HealtheVet?	Less than 6 months		Radio button, one-up vertical	Single	Y		PRYrsUse
			6 months - less than 1 year
			1-2 years
			More than 2 years
			Not sure/Do Not Recall
		In the past year, how frequently have you used the Blue Button to access your VA personal health record information?	Never		Radio button, one-up vertical	single	Y		PRTaskFreq1
			1-2 times
			3-9 times
			10 or more times
		In the past year, how frequently have you used Secure Messaging to communicate with your doctor or healthcare team?	Never		Radio button, one-up vertical	single	Y		PRTaskFreq2
			1-2 times
			3-9 times
			10 or more times
		In the past year, how frequently have you used My HealtheVet to check your upcoming VA appointments?	Never		Radio button, one-up vertical	single	Y		PRTaskFreq3
			1-2 times
			3-9 times
			10 or more times
		In the past year, how frequently have you used My HealtheVet to request a prescription refill?	Never		Radio button, one-up vertical	single	Y		PRTaskFreq4
			1-2 times
			3-9 times
			10 or more times
		In the past year, how frequently have you used My HealtheVet to check your VA prescription history?	Never		Radio button, one-up vertical	Multi	Y		PRMedFreq5
			1-2 times
			3-9 times
			10 or more times
		In the past year, how frequently have you used My HealtheVet Blue Button to check your VA Notes (the visit notes written by your VA healthcare team)?	Never		Radio button, one-up vertical	single	Y		PRTaskFreq6
			1-2 times
			3-9 times
			10 or more times
		In the past year, how frequently have you used My HealtheVet to check on your lab or test results (for example: blood tests, pathology reports, radiology reports, etc.)?	Never		Radio button, one-up vertical	single	Y		PRTaskFreq7
			1-2 times
			3-9 times
			10 or more times
		In the past year, how frequently have you used My HealtheVet to check your vitals and readings?	Never		Radio button, one-up vertical	single	Y		PRTaskFreq8
			1-2 times
			3-9 times
			10 or more times
		In the past year, how frequently have you used My HealtheVet to check your health summary using the VA Continuity of Care Document (VA CCD)?	Never		Radio button, one-up vertical	single	Y		PRTaskFreq9
			1-2 times
			3-9 times
			10 or more times
		In the past year, which of the following other types of information have you accessed in My HealtheVet or the VA Blue Button? (Please select all that apply)			Radio button, one-up vertical	Single	Y		PROTaskFreq
			VA Allergies and Adverse Reactions
			VA Immunizations
			VA Problem List (active health issues and conditions)
			VA Admissions and Discharges
			VA Wellness Reminders (for example: shots, cancer screening)
			Department of Defense (DoD) Military Service Information
		In the past year, how frequently have you used My HealtheVet to self-enter your medications and supplements?	Never		Radio button, one-up vertical	single	Y		PRSEFreq1
			1-2 times
			3-9 times
			10 or more times
		In the past year, how frequently have you used My HealtheVet to self-enter your labs and tests?	Never		Radio button, one-up vertical	single	Y		PRSEFreq2
			1-2 times
			3-9 times
			10 or more times
		In the past year, how frequently have you used My HealtheVet to self-enter your allergies and adverse reactions?	Never		Radio button, one-up vertical	single	Y		PRSEFreq3
			1-2 times
			3-9 times
			10 or more times
		In the past year, how frequently have you used My HealtheVet to self-enter your vitals and readings?	Never		Radio button, one-up vertical	single	Y		PRSEFreq4
			1-2 times
			3-9 times
			10 or more times
		In the past year, how frequently have you used My HealtheVet to self-enter information in your food journal?	Never		Radio button, one-up vertical	single	Y		PRSEFreq5
			1-2 times
			3-9 times
			10 or more times
		In the past year, how frequently have you used My HealtheVet to self-enter information in your activity journal?	Never		Radio button, one-up vertical	single	Y		PRSEFreq6
			1-2 times
			3-9 times
			10 or more times
		In the past year, how frequently have you used the My Goals feature in My HealtheVet to self-enter your health goals?	Never		Radio button, one-up vertical	single	Y		PRSEFreq7
			1-2 times
			3-9 times
			10 or more times
		In the past year, which other types of information have you self-entered into your My HealtheVet personal health record? (Please select all that apply)			Radio button, one-up vertical	Single	Y		PRSEOFreq
			Immunizations, self-reported
			Medical events, self-reported
			Family health history, self-reported
			Military health history, self-reported
			Treatment facility, self-reported
			Health insurance, self-reported
			Caregiver names and contacts, self-reported
			Health calendar, self-reported
			Personal information (contact information, emergency contacts), self-reported
			None of the above
		In the past year, how frequently have you communicated with your VA primary healthcare team about information that you self-entered into My HealtheVet? (for example: your home blood glucose or blood pressure measurements)	Never		Radio button, one-up vertical		Y		PRVASelfFreq
			1-2 times
			3-9 times
			10 or more times
		In the past year, how frequently have you communicated with your VA primary healthcare team about information that you accessed from your VA medical record in My HealtheVet? (for example: your VA Notes)	Never		Radio button, one-up vertical		Y		PRVAMHVFreq
			1-2 times
			3-9 times
			10 or more times
		In the past year, how frequently have you communicated with your other VA healthcare providers (for example: your specialist physicians, therapists, counselors and coordinators) about information that you self-entered into My HealtheVet?	Never		Radio button, one-up vertical		Y		PROtherSelfFreq
			1-2 times
			3-9 times
			10 or more times
		In the past year, how frequently have you communicated with your other VA healthcare providers (for example: your specialist physicians, therapists, counselors and coordinators) about information that you accessed from your VA medical record in My HealtheVet? (for example: your VA Notes)	Never		Radio button, one-up vertical		Y		PROtherMHVFreq
			1-2 times
			3-9 times
			10 or more times
		In the past year, how frequently have you used My HealtheVet information when you communicated with your VA healthcare team about care you received outside of the VA? (for example: tests done elsewhere or a non-VA emergency department visit)	Never		Radio button, one-up vertical	single	Y		PROutsideCare
			1-2 times
			3-9 times
			10 or more times
		In the past year, how frequently have you used My HealtheVet information when you communicated with your non-VA providers about care you received at the VA?	Never		Radio button, one-up vertical	single	Y		PRNonVAProvider
			1-2 times
			3-9 times
			10 or more times
		Which of the following methods do you use to access the My HealtheVet website? (Please select all that apply)	Computer or laptop		Checkbox, one-up vertical	Multi	Y		PRDevice
			Mobile phone (for example: iPhone, Android)
			Mobile tablet (for example: iPad, Android)
			Kiosk
			Television (for example: interactive Web TV )
			Other
[ORIENTING INTRODUCTION]		Your feedback is very important to us. Please think about your use of My HealtheVet features other than Secure Messaging when answering the following questions.
		The information in My HealtheVet is accurate.	Strongly disagree		Radio button, one-up vertical	Single	Y		PRAccurate
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do Not Recall
		The information in My HealtheVet is easy to understand.	Strongly disagree		Radio button, one-up vertical	Single	Y		PREasy
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do Not Recall
		New or updated information in My HealtheVet is generally available to me in a timely manner.	Strongly disagree		Radio button, one-up vertical	Single	Y		PRTimely
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do Not Recall
		My HealtheVet is a reliable system. (That is, I can always count on it working.)	Strongly disagree		Radio button, one-up vertical	Single	Y		PRProtect
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do Not Recall
		I am confident that My HealtheVet protects the privacy and security of my personal health information.	Strongly disagree		Radio button, one-up vertical	Single	Y		PRPrivate
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do Not Recall
		It is easy to find the different My HealtheVet features that I want to use.	Strongly disagree		Radio button, one-up vertical	Single	Y		PRONavToSM
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do Not Recall
		It is easy to navigate within the My HealtheVet features (for example, checking my VA Prescription status then requesting a refill).	Strongly disagree		Radio button, one-up vertical	Single	Y		PRNavInSM
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do Not Recall
		I trust my healthcare information when I receive it through My HealtheVet.	Strongly disagree		Radio button, one-up vertical	Single	Y		PRTrustOnline
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do Not Recall
		Regarding my personal health goals, I use My HealtheVet to help me: (Please select all that apply)			Checkbox, one-up vertical	Multi	Y		PRGoals
			Self-enter and track my personal health goals
			Gain peace of mind about my personal health goals
			Coordinate with my VA healthcare team based on my personal health goals
			Not sure/Do Not Recall
		Regarding my VA medications, I use My HealtheVet to help me: (Please select all that apply)			Checkbox, one-up vertical	Multi	Y		PRMeds
			Review and understand my VA-prescribed medications
			Gain peace of mind about my VA-prescribed medications
			Coordinate with my VA healthcare team about my VA-prescribed medications
			None of the above
		Regarding my VA tests and procedures, I use My HealtheVet to help me: (Please select all that apply)			Checkbox, one-up vertical	Multi	Y		PRTestPRoc
			Review and understand the tests and procedures that I receive from VA
			Gain peace of mind from my VA healthcare team about tests and procedures that I receive from VA
			Coordinate with my VA healthcare team about the tests and procedures that I receive from VA
			Not sure/Do Not Recall
		Regarding my mental and emotional health, I use My HealtheVet to help me: (Please select all that apply)			Checkbox, one-up vertical	Multi	Y		PRMentalHealth
			Review and understand my mental and emotional health and any prescribed treatment
			Gain peace of mind about my mental and emotional health and any prescribed treatment
			Coordinate with my VA healthcare team about my mental and emotional health and any prescribed treatment
			Not sure/Do Not Recall
		Regarding my VA preventive care (for example: screenings for type 2 diabetes, cholesterol, depression), I use My HealtheVet to help me: (Please select all that apply)			Checkbox, one-up vertical	Multi	Y		PRPreventive
			Review and understand my VA preventive care
			Gain peace of mind about my VA preventive care
			Coordinate with my VA healthcare team about my VA preventive care
			None of the above
		Regarding things I can do for my health (such as diet and exercise), I use My HealtheVet to help me: (Please select all that apply)	Review and understand specific things I can do to improve my health or prevent illness		Checkbox, one-up vertical	Multi	Y		PRSelfCare
			Self-enter and track specific things I can do to improve my health or prevent illness
			Gain peace of mind about specific things I can do to improve my health or prevent illness
			Coordinate with my VA healthcare team about specific things I can do to improve my health or prevent illness
			None of the above
		After treatment, labs or tests, I review my results on My HealtheVet to see if I need a follow-up call or visit.	Strongly disagree		Radio button, one-up vertical	Single	Y		PRFollowUp
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
		I use My HealtheVet information to help me make better health and healthcare decisions.	Strongly disagree		Radio button, one-up vertical	Single	Y		PRDecisInfo
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
		I use My HealtheVet to help me judge when it is necessary to call or go see my VA healthcare team.	Strongly disagree		Radio button, one-up vertical	Single	Y		PRDecisCall
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
		I use My HealtheVet to help me figure out solutions when new problems arise with my health.	Strongly disagree		Radio button, one-up vertical	Single	Y		PRSolutions
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
		I have all the information I need to manage my health and healthcare.	Strongly disagree		Radio button, one-up vertical	Single	Y		OUTInfo
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
		I am confident in working with my VA healthcare team to manage my health and healthcare.	Strongly disagree		Radio button, one-up vertical	Single	Y		OUTTeam
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
		I feel in control of my health and healthcare (such as taking part in decisions or following through on any medication, treatment or health routine).	Strongly disagree		Radio button, one-up vertical	Single	Y		OUTControl
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
		I am able to achieve my long-term health and healthcare goals (such as being self-reliant, living longer and better, or knowing that my family and friends can depend on me.)	Strongly disagree		Radio button, one-up vertical	Single	Y		OUTAchGoals
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
		I intend to continue using My HealtheVet in the future.	Strongly disagree		Radio button, one-up vertical	Single	Y		OUTIntentUse
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
		I intend to recommend My HealtheVet to others.	Strongly disagree		Radio button, one-up vertical	Single	Y		OUTIntentRec
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
CAS0042818		In the past year, have you ever used Secure Messaging to communicate electronically with your VA doctor or healthcare team?	Yes	A,B,C, D1-D9,E, F,G, H, I, J, K, L, M, N, O,P, Q, R,S,T,U, V,W,X,Y,Z,AA,BB,CC,DD,EE,FF,GG	Checkbox, one-up vertical	Single	Y	Skip Logic	SBLEverUsed
			No	ZZ
			Not Sure/Do Not Recall	ZZ
Secure Messaging Users (A-HH)
CAS0042819	A	Which of the following convinced you to first try Secure Messaging? (Check all that apply)	My doctor uses it		Checkbox, three-up vertical	Multi	Y	Skip Logic	SPRTrial
			My doctor recommended it to me
			Someone on my VA healthcare team other than my doctor recommended it to me.
			Another Veteran recommended it to me
			I received a hands-on demonstration at the VA facility.
			I saw a video program or a poster at the VA facility.
			I saw the Secure Messaging feature when I was using My HealtheVet for another task.
			I read a printed fact sheet.
			I received a postcard.
			I received an email reminder.
			I received a phone call from the VA.
			I read or heard about it through the media (newspaper, radio, TV, or social media like Facebook or Twitter).
			I received or saw information materials provided in Spanish.
			Other
			Not sure/Do Not Recall
CAS0042820	B	How long have you been using Secure Messaging?	Less than 6 months		Radio button, one-up vertical	Single	Y	Skip Logic	SPRYrsUse
			6 months - less than 1 year
			1-2 years
			More than 2 years
			Not sure/Do Not Recall
CAS0042821	C	Generally, how frequently do you use Secure Messaging?	This is my first time		Radio button, one-up vertical	Single	Y	Skip Logic	SPRFreqUse
			Less than every 6 months
			About every 6 months
			About once a month
			About once a week
			Daily
			Not sure/Do Not Recall
CAS0042882	D1	In the past year, how frequently have you used Secure Messaging to ask questions about your health?	Never		Radio button, one-up vertical	single	Y	Skip Logic	SPRTaskFreq1
			1-2 times
			3-9 times
			10 or more times
CAS0042883	D2	In the past year, how frequently have you used Secure Messaging to request an appointment?	Never		Radio button, one-up vertical	single	Y	Skip Logic	SPRTaskFreq2
			1-2 times
			3-9 times
			10 or more times
CAS0042870	D3	In the past year, how frequently have you used Secure Messaging to request prescription refills or renewal?	Never		Radio button, one-up vertical	single	Y	Skip Logic	SPRTaskFreq3
			1-2 times
			3-9 times
			10 or more times
CAS0042871	D4	In the past year, how frequently have you used Secure Messaging to ask about procedures received performed?	Never		Radio button, one-up vertical	single	Y	Skip Logic	SPRTaskFreq4
			1-2 times
			3-9 times
			10 or more times
CAS0042872	D5	In the past year, how frequently have you used Secure Messaging to ask questions about your lab or test results (ex. pathology, radiology, EKG)?	Never		Radio button, one-up vertical	single	Y	Skip Logic	SPRTaskFreq5
			1-2 times
			3-9 times
			10 or more times
CAS0042873	D6	In the past year, how frequently have you used Secure Messaging to ask about self-care recommendations from your healthcare team?	Never		Radio button, one-up vertical	single	Y	Skip Logic	SPRTaskFreq6
			1-2 times
			3-9 times
			10 or more times
CAS0042874	D7	In the past year, how frequently have you used Secure Messaging to ask questions about your own health tracking (ex. exercise, sleep)?	Never		Radio button, one-up vertical	single	Y	Skip Logic	SPRTaskFreq7
			1-2 times
			3-9 times
			10 or more times
CAS0042875	D8	In the past year, how frequently have you used Secure Messaging to send health information to your VA healthcare team (for example: your home blood glucose or blood pressure measurements)?	Never		Radio button, one-up vertical	single	Y	Skip Logic	SPRTaskFreq8
			1-2 times
			3-9 times
			10 or more times
CAS0042876	D9	In the past year, how frequently have you used Secure Messaging to update your VA healthcare team about care received outside of the VA (or example: tests done elsewhere or a non-VA emergency department visit)?	Never		Radio button, one-up vertical	single	Y	Skip Logic	SPRTaskFreq9
			1-2 times
			3-9 times
			10 or more times
CAS0042878	F	How have you used Secure Messaging to communicate with your VA healthcare team about your medications? (Please select all that apply)	To ask questions about the purpose of VA prescribed medications		Checkbox, one-up vertical	Multi	Y	skip Logic	SPRMedFreq
			To ask questions about the correct dose of my VA prescribed medications
			To ask questions about or report side effects of my VA prescribed medications
			To ask questions about or report side effects of my non-VA prescribed medications
			To ask questions about or report side effects of my over-the-counter medications
			To ask questions about or report interactions between multiple medications
			Other
			None of the above
			Not sure/Do Not Recall
CAS0042879	G	Which of the following methods do you use to access the My HealtheVet website? (Please select all that apply)	Computer or laptop		Checkbox, one-up vertical	Multi	Y	Skip Logic	SPRDevice
			Mobile phone (ex. iPhone, Android)
			Mobile tablet (ex. iPad, Android)
			Kiosk
			Television (ex. interactive Web TV )
			Other
CAS0042851	H	Which aspects of Secure Messaging do you find most useful? (Please select all that apply)	I can write or retrieve a message anytime, day or night		Checkbox, one-up vertical	Multi	Y	Skip Logic	SPRBenefits
			I can write a message, or review a response, at my own speed
			I can use it on any device (through a computer, a smart tablet or smart phone)
			I can access it anywhere (at home, work, library or other location)
			I can leave a message instead of calling or visiting my VA healthcare team
			I can get answers or solutions specific to my needs from my VA healthcare team
			I can get answers or solutions on topics that I might find difficult or uncomfortable to discuss in person with my VA healthcare team
			I can share my secure message information with those I trust
			I can print a paper copy of my secure messages
			I can access and store all of my secure messages in one place
			Other
			Not sure/Do Not Recall
CAS0042852	I	Your experience with Secure Messaging is important to us. Please share your thoughts on the following qualities that contribute to its function and service.The information that my VA healthcare team provides to me through Secure Messaging is accurate. (That is, my team is up to date on all of my health records and medications.)	Strongly disagree		Radio button, one-up vertical	Single	Y	Skip Logic	SPRAccurate
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do Not Recall
CAS0042853	J	In Secure Messaging, my VA healthcare team helps make the information we discuss easy to understand.	Strongly disagree		Radio button, one-up vertical	Single	Y	Skip Logic	SPREasy
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do Not Recall
CAS0042854	K	Generally, my VA healthcare team responds to my messages within 3 business days.	Strongly disagree		Radio button, one-up vertical	Single	Y	Skip Logic	SPRTimely
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do Not Recall
CAS0042855	L	Secure Messaging is a reliable system. (That is, I can always count on it working.)	Strongly disagree		Radio button, one-up vertical	Single	Y	Skip Logic	SPRProtect
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do Not Recall
CAS0042857	M	I am confident that Secure Messaging protects the privacy and security of my personal health information.	Strongly disagree		Radio button, one-up vertical	Single	Y	Skip Logic	PRPrivate
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do Not Recall
CAS0042858	N	It is easy to find the Secure Messaging feature on My HealtheVet .	Strongly disagree		Radio button, one-up vertical	Single	Y	Skip Logic	SPRONavToSM
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do Not Recall
CAS0042859	O	It is easy to navigate within the Secure Messaging feature.	Strongly disagree		Radio button, one-up vertical	Single	Y	Skip Logic	SPRNavInSM
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do Not Recall
CAS0042884	P	I trust my VA healthcare team's advice and care when I receive it through Secure Messaging.	Strongly disagree		Radio button, one-up vertical	Single	Y	Skip Logic	SPRTrustOnline
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do Not Recall
CAS0042885	Q	Once again, your experience with Secure Messaging is important to us. Please share your thoughts on how you use Secure Messaging to support your health and healthcare. Regarding my personal health goals, I use Secure Messaging to help me: (Please select all that apply)	Review and understand my personal health goals		Radio button, one-up vertical	Multi	Y	Skip Logic	PRGoals
			Gain peace of mind from my VA healthcare team about my personal health goals
			Coordinate with my VA healthcare team based on my personal health goals
			Not sure/Do Not Recall
CAS0042886	R	Regarding my VA medications, I use Secure Messaging to help me: (Please select all that apply)	Review and understand my VA-prescribed medications		Radio button, one-up vertical	Multi	Y	Skip Logic	SPRMeds
			Gain peace of mind from my VA healthcare team about my VA-prescribed medications
			Coordinate with my VA healthcare team about my VA-prescribed medications
			None of the above
CAS0042887	S	Regarding my VA tests and procedures, I use Secure Messaging to help me: (Please select all that apply)	Review and understand the tests and procedures that I received from the VA		Radio button, one-up vertical	Multi	Y	Skip Logic	SPRTestsProc
			Gain peace of mind from my VA healthcare team about tests and procedures that I receive from the VA
			Coordinate with my VA healthcare team about the tests and procedures that I receive from the VA
			Not sure/Do Not Recall
CAS0042888	T	Regarding my mental and emotional health, I use Secure Messaging to help me: (Please select all that apply)	Review and understand my mental and emotional health and any prescribed treatment		Radio button, one-up vertical	Multi	Y	Skip Logic	SPRMentalHealth
			Gain peace of mind from my VA healthcare team about my mental and emotional health and any prescribed treatment
			Coordinate with my VA healthcare team about my mental and emotional health and any prescribed treatment
			Not sure/Do Not Recall
CAS0042889	U	Regarding my VA preventive care (for example: screenings for Type 2 diabetes, cholesterol, depression), I use Secure Messaging to help me: (Please select all that apply)	Review and understand VA preventive care		Radio button, one-up vertical	Multi	Y	Skip Logic	SPRPreventive
			Gain peace of mind from my VA healthcare team about my VA preventive care
			Coordinate with my VA healthcare team about my VA preventive care
			None of the above
CAS0042890	V	Regarding things I can do for my health (such as diet and exercise), I use Secure Messaging to help me: (Please select all that apply)	Review and understand specific things I can do to improve my health or prevent illness		Radio button, one-up vertical	Multi	Y	Skip Logic	SPRSelfCare
			Gain peace of mind about specific things I can do to improve my health or prevent illness
			Coordinate with my VA healthcare team about specific things I can do to improve my health or prevent illness
			None of the above
CAS0042891	W	My VA healthcare team uses Secure Messaging to follow up with me regarding lab results, tests, or procedures	Strongly disagree		Radio button, one-up vertical	Single	Y	Skip Logic	SPRFollowUp
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
CAS0042892	X	I use Secure Messaging information to help me make better health and healthcare decisions.	Strongly disagree		Radio button, one-up vertical	Single	Y	Skip Logic	SPRDecisInfo
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
CAS0042893	Y	I use Secure Messaging to help me judge when it is necessary to call or go see my VA healthcare team.	Strongly disagree		Radio button, one-up vertical	Single	Y	Skip Logic	SPRDecisCall
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
CAS0042894	Z	In addition to communication with my primary VA healthcare team, I use Secure Messaging to communicate with my other VA healthcare providers (for example: specialist physicians, therapists, counselors and coordinators).	Strongly disagree		Radio button, one-up vertical	Single	Y	Skip Logic	SPROthProvider
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
CAS0042895	AA	I use Secure Messaging to help me figure out solutions when new problems arise with my health.	Strongly disagree		Radio button, one-up vertical	Single	Y	Skip Logic	SPRSolutions
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
CAS0042896	BB	I have all the information I need to manage my health and healthcare.	Strongly disagree		Radio button, one-up vertical	Single	Y	Skip Logic	SOUTInfo
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
CAS0042897	CC	I am confident in working with my VA healthcare team to manage my health and healthcare.	Strongly disagree		Radio button, one-up vertical	Single	Y	Skip Logic	SOUTTeam
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
CAS0042898	DD	I feel in control of my health and healthcare (such as taking part in decisions or following through on any medication, treatment or health routine schedule).	Strongly disagree		Radio button, one-up vertical	Single	Y	Skip Logic	SOUTControl
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
CAS0042899	EE	I am able to achieve my long-term health and healthcare goals (such as being self-reliant, living longer and better, or knowing that my family and friends can depend on me.)	Strongly disagree		Radio button, one-up vertical	Single	Y	Skip Logic	SOUTAchGoals
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
CAS0042900	FF	I intend to continue using Secure Messaging in the future.	Strongly disagree		Radio button, one-up vertical	Single	Y	Skip Logic	SOUTIntentUse
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
CAS0042901	GG	I intend to recommend Secure Messaging to others.	Strongly disagree		Radio button, one-up vertical	Single	Y	Skip Logic	SOUTIntentRec
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
Secure Messaging Non-Users/Don't recall (ZZ-)
CAS0042860	ZZ	Why Not?	This is the first time that I have heard of Secure Messaging	ZZ1	Radio button, one-up vertical	Multi	Y	Skip Logic	SBLWhyNot
			I have heard of Secure Messaging, but have not tried it or have not been able to use it	ZZ2
CAS0042861	ZZ1	I would be interested in trying Secure Messaging if:	Someone on my VA healthcare team recommended it to me		Checkbox, one-up vertical	Multi	Y	Skip	SBLInterest
			Another Veteran recommended it to me
			I received more information on the benefits of Secure Messaging
			The VA provided me with hands-on training as part of my next VA appointment
			The VA provided me with training through a web video that I could access anytime through my own computer or mobile device
			The VA provided an instruction sheet on My HealtheVet that I could read or print out
			Not sure
			Other
CAS0042902	ZZ2	I have heard of Secure Messaging but have not tried or have not been able to use it because: (Please select all that apply)	I did not understand what Secure Messaging is		Checkbox, one-up vertical	Multi	Y	Skip	SBLWhyNotUsed
			I have not signed up for a Premium My HealtheVet account. (Authenticated Account)
			I have a Premium My HealtheVet account, but did not know where to look for the Secure Messaging. (Authenticated Account)
			I am not interested in Secure Messaging
			I believe it will be too hard or time-consuming to use
			When I have a question or request that doesn't require a visit, I prefer to talk on the phone with my VA healthcare team
			I believe that the response that I may receive from my VA healthcare team would not fully address my information needs
			I feel uncertain about the privacy and security of my personal health information using Secure Messaging.
			I do not have regular access to a computer, smart phone or tablet
			Not sure/Do not recall
CAS0042903		In the past year, have you used My HealtheVet to accomplish any of the following tasks? (please select all that apply)	Use the Blue Button (Download My Data)		Checkbox, one-up vertical	Multi	Y		SPRMultiuse
			Refill my prescriptions
			View my medications information
			View my VA Notes (written by my health care team)
			View my lab or other test results
			View my VA Wellness Reminders
			Review my medical history (conditions, procedures, accidents and events)
			Research my health using education resources (for example, the My HealtheVet Medical Library)
			Enter data that I track myself such as weight, blood pressure, blood sugar, etc.
			Enter information about my non-VA medications or supplements
			None of the above
CAS0042904		How often do you find that information from the VA (in print or online) about your medical condition is difficult to understand?	Never or almost never		Radio button, one-up vertical	Single	Y		ANHlthLit
			Infrequently
			Occasionally
			Frequently
			Very frequently or always
			Not sure/Do not recall
RJB00029		My use of the My HealtheVet personal health record has improved my ability to manage my health.	Strongly agree		Radio button, one-up vertical	Single	Y		MHV improve Health
			Agree
			Not sure
			Disagree
			Strongly disagree
			Not applicable
CAS0042905		Overall, how confident are you that you could get health-related advice or information if you needed it by using a computer, smart phone or tablet (like an iPhone or iPad)?	Not at all confident		Radio button, one-up vertical	Single	Y		ANHlthSearch
			Somewhat confident
			Moderately confident
			Confident
			Very confident
			Not sure
CAS0029040		What additional services would you like to see on My HealtheVet? (Please select all that apply)	Schedule or change my VA appointments		Checkbox, one-up vertical	Multi	N		Additional Services
			Track the status of my prescription refill delivery
			View/pay my VA bills/copayments
			View a list of my VA health care providers and their contact information
			Use a mobile app for My HealtheVet
			Join an online forum to discuss health issues with other Veterans
			Advance check-in for my VA clinic visits
			Authorize sharing information I have stored in My HealtheVet with other people (e.g., family, caregiver)
			Authorize sharing information that I have stored in My HealtheVet with my VA health care team
			Authorize sharing information that I have stored in My HealtheVet with my Non-VA health care provider
			Check to determine if my different medications are safe when taken together
			More online educational programs
			Receive a monthly email newsletter
			Receive notification of new content/features on the site
			Other
ALM0173		What is the main improvement that you would suggest for the My HealtheVet web site?			Text area, no char limit		N		ENDRequest
AED06379		Have you completed this survey within the past 3 months?	Yes		Radio button, one-up vertical				Survey
			No			Single	N
			Don't recall

---

Sheet 10: Current Custom Qsts (11-8-13)

Model Instance Name: VA - My HealtheVet			red & strike-through: DELETE
MID:	NJxFtMU9UosBkJZRd48x9Q==		underlined & italicized: RE-ORDER	Wave 1 Set
			pink: ADDITION
Date:	6/23/2009		blue + -->: REWORDING
			violet (bold): SKIP-LOGIC
MID: CUSTOM QUESTION LIST
QID	Skip Logic Label	Question Text	Answer Choices (limited to 50 characters)	Skip to	Type (select from list)	Single or Multi	Required Y/N	Special Instructions	Question Label
ALM0170		Which of the following best describes you?	Active duty		Checkbox, one-up vertical	Multi	Y		SANRole
			National Guard/Reserve
			Veteran
			Family member of a veteran or Servicemember
			Caregiver of a Veteran or Servicemember (other than family)
			Veteran Service Organization member
			VA employee
			Non-VA federal government employee
			State/local government employee
			General public
			Other role
RJB00048		Please indicate your military period(s) of service:	Global War on Terror (OEF/OIF/OND)		Checkbox, one-up vertical	Multi	N		SANMilServ
			Desert Shield/Desert Storm
			Vietnam War
			Korean War
			World War II
			Peacetime Service
			Other
			Not Applicable
AED02714		What is your age range?	Under 20		Dropdown (Select-one)	Single	N		SANAge
			20-24
			25-29
			30-34
			35-39
			40-44
			45-49
			50-54
			55-59
			60-64
			65-69
			70-74
			75-79
			80-84
			85 or older
JIC00267		What is your gender?	Male		Dropdown (Select-one)	Single	N		SANGender
			Female
		Are you of Hispanic or Latino origin or descent?	Yes		Drop down, select one	Single	N		SANEthnicity
			No
		What is your race?	American Indian or Alaska Native		Drop down, select one	Single	N		SANRace
			Asian
			Black or African American
			Native Hawaiian or Other Pacific Islander
			White (Caucasian)
			Two or More Races
			Other race, please specify
			Unknown or Do Not Wish to Reply
		Other race			Text area, no char limit		N		ANRace_Other
CAS0028939		Which of the following best describes the highest level of education you have completed?	Did not complete high school		Radio button, one-up vertical	Single	Y		SANEduc
			High school graduate
			Some college or vocational school
			College graduate
			Some postgraduate school
			Graduate or professional degree
JIC00178		In general, how would you rate your overall health?	Excellent		Drop down, select one	Single	Y		SANHealth
			Very Good
			Good
			Fair
			Poor
RJB00026		Are you a registered user on the MyHealtheVet web site?	Yes	A	Checkbox, one-up vertical	Single	Y	Skip Logic	SANRegUser
			No
			Not sure
CAS0028940	A	Your member log-in box now includes an icon for your account type. What type of My HealtheVet account do you have?	Basic (B)		Checkbox, one-up vertical	Single	Y	Skip Logic	SANUserType
			Advanced (A)
			Premium (authenticated or IPA’d)(P)
			Not sure
ALM0169		How frequently do you visit the My HealtheVet web site?	First time		Dropdown (Select-one)	Single	Y		SANMHVFreq
			Daily or more than once a day
			Daily
			More than once a day
			About once a week
			About once a month
			About every 6 months
			Less than every 6 months
			Not sure/Do not recall
RJB00022		What were you trying to accomplish today in My HealtheVet? (please select all that apply)			Checkbox, one-up vertical	Multi	Y		SANReason
			Learn more about features that are available
			Request a prescription refill
			View my medication history
			Use Secure Messaging to communicate with my VA health care team
			Use the Blue Button (Download My Data)
			View my VA Appointments
			Look up information about a health condition or medication
			View my lab or other test results
			View my VA Wellness Reminders
			View my VA Notes (written by my health care team)
			Enter my personal information (emergency contacts, etc.)
			Enter data that I track myself such as weight, blood pressure, blood sugar, etc.
			Enter information about my non-VA medications or supplements
			Find a VA facility
			Find information about VA Health Benefits
			Find information about VA Benefits other than health benefits
			Other (please specify)	A
RJB00022other	A	Other - trying to accomplish			Text field, <100 char	Single	N
ALM0172		Did you accomplish what you wanted to in My HealtheVet?	Yes		Dropdown (Select-one)	Single	Y		SANTaskAcc
			No
			Partially
			Not finished yet
CAS0028943		Do you get care at a VA facility?	Yes	A,B	Checkbox, one-up vertical	Single	Y	Skip Logic	SANFacilCare
			No
			Not Sure
CAS0028944	A	In the past year, how often did you use a VA medical facility or service for your health care needs?	Never		Checkbox, one-up vertical	Single	N	skip logic	SANFacilFreq
			Once in the past year
			2 to 11 times in the past year
			12 or more times in the past year
	B	What is your travel time to the VA facility where you receive most of your care?	less than 30 minutes		Checkbox, one-up vertical	Single	Y	skip logic	SANDist
			30 minutes to under 1 hour
			1 hour to under 1.5 hours
			1.5 hours to under 2 hours
			Not sure/Do not recall
CAS0028945	B	How much time does it take for you to travel to the nearest VA facility?	Less than 15 minutes		Checkbox, one-up vertical	single	N	skip logic	VA Facility Travel Time
			15 minutes to less than 1/2 hour
			1/2 hour to less than an hour
			An hour to less than 1 1/2 hours
			1 1/2 hours to less than two hours
			Two hours or more
			Not sure
		How many years have you been seeing your VA primary healthcare team?	Less than 1 year		Drop down, select one	Single	Y		SANYrsTeam
			1-5 years
			More than 5 years
			Not sure/Do not recall
		Generally speaking, how satisfied are you with the quality of care and treatment that you receive from your VA healthcare team?	Very unsatisfied		Drop down, select one	Single	Y		SANSatTeam
			Unsatisfied
			Neither satisfied nor unsatisfied
			Satisfied
			Very satisfied
			Not sure/Do not recall
		Overall, I trust my VA healthcare team's advice and care.	Strongly disagree		Drop down, select one	Single	Y		SANTrustTeam
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do not recall
NEW MEANINGFUL USE QUESTION ROTATION
		Has your VA doctor or healthcare team ever recommended Secure Messaging to you?	Yes			Single	Y		SPREverUsed
			No
			Not Sure/Do Not Recall
		In the past year, have you ever used Secure Messaging to communicate electronically with your VA doctor or healthcare team?	Yes	A,B,C, D1-D9,E, F,G, H, I, J, K, L, M, N, O,P, Q, R,S,T,U, V,W,X,Y,Z,AA,BB,CC,DD,EE,FF,GG,HH	Checkbox, one-up vertical	Single	Y	Skip Logic	SBLEverUsed
			No	ZZ
			Not Sure/Do Not Recall	ZZ
Secure Messaging Users (A-HH)
	A	Which of the following convinced you to first try Secure Messaging? (Check all that apply)	My doctor uses it		Checkbox, three-up vertical	Multi	Y	Skip Logic	SPRTrial
			My doctor recommended it to me
			Someone on my VA healthcare team other than my doctor recommended it to me.
			Another Veteran recommended it to me
			I received a hands-on demonstration at the VA facility.
			I saw a video program or a poster at the VA facility.
			I saw the Secure Messaging feature when I was using My HealtheVet for another task.
			I read a printed fact sheet.
			I received a postcard.
			I received an email reminder.
			I received a phone call from the VA.
			I read or heard about it through the media (newspaper, radio, TV, or social media like Facebook or Twitter).
			I received or saw information materials provided in Spanish.
			Other
			Not sure/Do Not Recall
	B	How long have you been using Secure Messaging?	Less than 6 months		Drop down, select one	Single	Y	Skip Logic	SPRYrsUse
			6 months - less than 1 year
			1-2 years
			More than 2 years
			Not sure/Do Not Recall
	C	Generally, how frequently do you use Secure Messaging?	This is my first time		Drop down, select one	Single	Y	Skip Logic	SPRFreqUse
			Less than every 6 months
			About every 6 months
			About once a month
			About once a week
			Daily
			Not sure/Do Not Recall
	D1	In the past year, how frequently have you used Secure Messaging to ask questions about your health?	Never		Drop down, select one	single	Y	Skip Logic	SPRTaskFreq1
			1-2 times
			3-9 times
			10 or more times
	D2	In the past year, how frequently have you used Secure Messaging to request an appointment?	Never		Drop down, select one	single	Y	Skip Logic	SPRTaskFreq2
			1-2 times
			3-9 times
			10 or more times
	D3	In the past year, how frequently have you used Secure Messaging to request prescription refills or renewal?	Never		Drop down, select one	single	Y	Skip Logic	SPRTaskFreq3
			1-2 times
			3-9 times
			10 or more times
	D4	In the past year, how frequently have you used Secure Messaging to ask about procedures received?	Never		Drop down, select one	single	Y	Skip Logic	SPRTaskFreq4
			1-2 times
			3-9 times
			10 or more times
	D5	In the past year, how frequently have you used Secure Messaging to ask questions about your lab or test results (ex. pathology, radiology, EKG)?	Never		Drop down, select one	single	Y	Skip Logic	SPRTaskFreq5
			1-2 times
			3-9 times
			10 or more times
	D6	In the past year, how frequently have you used Secure Messaging to ask about self-care recommendations from your healthcare tea?	Never		Drop down, select one	single	Y	Skip Logic	SPRTaskFreq6
			1-2 times
			3-9 times
			10 or more times
	D7	In the past year, how frequently have you used Secure Messaging to ask questions about your own health tracking (ex. exercise, sleep)?	Never		Drop down, select one	single	Y	Skip Logic	SPRTaskFreq7
			1-2 times
			3-9 times
			10 or more times
	D8	In the past year, how frequently have you used Secure Messaging to send health information to your VA healthcare team (for example: your home blood glucose or blood pressure measurements)?	Never		Drop down, select one	single	Y	Skip Logic	SPRTaskFreq8
			1-2 times
			3-9 times
			10 or more times
	D9	In the past year, how frequently have you used Secure Messaging to update your VA healthcare team about care received outside of the VA (or example: tests done elsewhere or a non-VA emergency department visit)?	Never		Drop down, select one	single	Y	Skip Logic	SPRTaskFreq9
			1-2 times
			3-9 times
			10 or more times
	E	In the past year, please describe how else you have used secure messaging			Text area, no char limit		N		SPRTaskFreqOth
	F	How have you used Secure Messaging to communicate with your VA healthcare team about your medications? (Please select all that apply)	To ask questions about the purpose of VA prescribed medications		Checkbox, one-up vertical	Multi	Y	skip Logic	SPRMedFreq
			To ask questions about the correct dose of my VA prescribed medications
			To ask questions about or report side effects of my VA prescribed medications
			To ask questions about or report side effects of my non-VA prescribed medications
			To ask questions about or report side effects of my over-the-counter medications
			To ask questions about or report interactions between multiple medications
			Other
			None of the above
			Not sure/Do Not Recall
	G	Which of the following methods do you use to access the My HealtheVet website? (Please select all that apply)	Computer or laptop		Checkbox, one-up vertical	Multo	Y	Skip Logic	SPRDevice
			Mobile phone (ex. iPhone, Android)
			Mobile tablet (ex. iPad, Android)
			Kiosk
			Television (ex. interactive Web TV )
			Other
	H	Which aspects of Secure Messaging do you find most useful? (Please select all that apply)	I can write or retrieve a message anytime, day or night		Checkbox, one-up vertical	Multi	Y	Skip Logic	SPRBenefits
			I can write a message, or review a response, at my own speed
			I can use it on any device (through a computer, a smart tablet or smart phone)
			I can access it anywhere (at home, work, library or other location)
			I can leave a message instead of calling or visiting my VA healthcare team
			I can get answers or solutions specific to my needs from my VA healthcare team
			I can get answers or solutions on topics that I might find difficult or uncomfortable to discuss in person with my VA healthcare team
			I can share my secure message information with those I trust
			I can print a paper copy of my secure messages
			I can access and store all of my secure messages in one place
			Other		Text area, no char limit		N		SPRBenefitsOth
			Not sure/Do Not Recall
	I	The information that my VA healthcare team provides to me through Secure Messaging is accurate. (That is, my team is up to date on all of my health records and medications.)	Strongly disagree		Drop down, select one	Single	Y	Skip Logic	SPRAccurate
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do Not Recall
	J	In Secure Messaging, my VA healthcare team helps make the information we discuss easy to understand.	Strongly disagree		Drop down, select one	Single	Y	Skip Logic	SPREasy
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do Not Recall
	K	Generally, my VA healthcare team responds to my messages within 3 business days.	Strongly disagree		Drop down, select one	Single	Y	Skip Logic	SPRTimely
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do Not Recall
	L	Secure Messaging is a reliable system. (That is, I can always count on it working.)	Strongly disagree		Drop down, select one	Single	Y	Skip Logic	SPRProtect
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do Not Recall
	M	I am confident that Secure Messaging protects the privacy and security of my personal health information.	Strongly disagree		Drop down, select one	Single	Y	Skip Logic	PRPrivate
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do Not Recall
	N	It is easy to find the Secure Messaging feature on My HealtheVet .	Strongly disagree		Drop down, select one	Single	Y	Skip Logic	SPRONavToSM
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do Not Recall
	O	It is easy to navigate within the Secure Messaging feature.	Strongly disagree		Drop down, select one	Single	Y	Skip Logic	SPRNavInSM
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do Not Recall
	P	I trust my VA healthcare team's advice and care when I receive it through Secure Messaging.	Strongly disagree		Drop down, select one	Single	Y	Skip Logic	SPRTrustOnline
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
			Not sure/Do Not Recall
	Q	Regarding my personal health goals, I use Secure Messaging to help me: (Please select all that apply)	Review and understand my personal health goals		Checkbox, one-up vertical	Multi	Y	Skip Logic	PRGoals
			Gain peace of mind from my VA healthcare team about my personal health goals
			Coordinate with my VA healthcare team based on my personal health goals
			Not sure/Do Not Recall
	R	Regarding my VA medications, I use Secure Messaging to help me: (Please select all that apply)	Review and understand my VA-prescribed medications		Checkbox, one-up vertical	Multi	Y	Skip Logic	SPRMeds
			Gain peace of mind from my VA healthcare team about my VA-prescribed medications
			Coordinate with my VA healthcare team about my VA-prescribed medications
			None of the above
	S	Regarding my VA tests and procedures, I use Secure Messaging to help me: (Please select all that apply)	Review and understand the tests and procedures that I received from the VA		Checkbox, one-up vertical	Multi	Y	Skip Logic	SPRTestsProc
			Gain peace of mind from my VA healthcare team about tests and procedures that I receive from the VA
			Coordinate with my VA healthcare team about the tests and procedures that I receive from the VA
			Not sure/Do Not Recall
	T	Regarding my mental and emotional health, I use Secure Messaging to help me: (Please select all that apply)	Review and understand my mental and emotional health and any prescribed treatment		Checkbox, one-up vertical	Multi	Y	Skip Logic	SPRMentalHealth
			Gain peace of mind from my VA healthcare team about my mental and emotional health and any prescribed treatment
			Coordinate with my VA healthcare team about my mental and emotional health and any prescribed treatment
			Not sure/Do Not Recall
	U	Regarding my VA preventive care (for example: screenings for Type 2 diabetes, cholesterol, depression), I use Secure Messaging to help me: (Please select all that apply)	Review and understand VA preventive care		Checkbox, one-up vertical	Multi	Y	Skip Logic	SPRPreventive
			Gain peace of mind from my VA healthcare team about my VA preventive care
			Coordinate with my VA healthcare team about my VA preventive care
			None of the above
	V	Regarding things I can do for my health (such as diet and exercise), I use Secure Messaging to help me: (Please select all that apply)	Review and understand specific things I can do to improve my health or prevent illness		Checkbox, one-up vertical	Multi	Y	Skip Logic	SPRSelfCare
			Gain peace of mind about specific things I can do to improve my health or prevent illness
			Coordinate with my VA healthcare team about specific things I can do to improve my health or prevent illness
			None of the above
	W	My VA healthcare team uses Secure Messaging to follow up with me regarding lab results, tests, or procedures	Strongly disagree		Drop down, select one	Single	Y	Skip Logic	SPRFollowUp
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
	X	I use Secure Messaging information to help me make better health and healthcare decisions.	Strongly disagree		Drop down, select one	Single	Y	Skip Logic	SPRDecisInfo
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
	Y	I use Secure Messaging to help me judge when it is necessary to call or go see my VA healthcare team.	Strongly disagree		Drop down, select one	Single	Y	Skip Logic	SPRDecisCall
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
	Z	In addition to communication with my primary VA healthcare team, I use Secure Messaging to communicate with my other VA healthcare providers (for example: specialist physicians, therapists, counselors and coordinators).	Strongly disagree		Drop down, select one	Single	Y	Skip Logic	SPROthProvider
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
	AA	I use Secure Messaging to help me figure out solutions when new problems arise with my health.	Strongly disagree		Drop down, select one	Single	Y	Skip Logic	SPRSolutions
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
	BB	I have all the information I need to manage my health and healthcare.	Strongly disagree		Drop down, select one	Single	Y	Skip Logic	SOUTInfo
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
	CC	I am confident in working with my VA healthcare team to manage my health and healthcare.	Strongly disagree		Drop down, select one	Single	Y	Skip Logic	SOUTTeam
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
	DD	I feel in control of my health and healthcare (such as taking part in decisions or following through on any medication, treatment or health routine schedule).	Strongly disagree		Drop down, select one	Single	Y	Skip Logic	SOUTControl
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
	EE	I am able to achieve my long-term health and healthcare goals (such as being self-reliant, living longer and better, or knowing that my family and friends can depend on me.)	Strongly disagree		Drop down, select one	Single	Y	Skip Logic	SOUTAchGoals
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
	FF	I intend to continue using Secure Messaging in the future.	Strongly disagree		Drop down, select one	Single	Y	Skip Logic	SOUTIntentUse
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
	GG	I intend to recommend Secure Messaging to others.	Strongly disagree		Drop down, select one	Single	Y	Skip Logic	SOUTIntentRec
			Disagree
			Neither agree nor disagree
			Agree
			Strongly agree
Secure Messaging Non-Users/Don't recall (ZZ-)
	ZZ	Why Not?	This is the first time that I have heard of Secure Messaging	ZZ1	Checkbox, one-up vertical	Multi	Y	Skip Logic	SBLWhyNot
			I have heard of Secure Messaging, but have not tried it or have not been able to use it	ZZ2
	ZZ1	I would be interested in trying Secure Messaging if:	Someone on my VA healthcare team recommended it to me		Checkbox, one-up vertical	Multi	Y	Skip	SBLInterest
			Another Veteran recommended it to me
			I received more information on the benefits of Secure Messaging
			The VA provided me with hands-on training as part of my next VA appointment
			The VA provided me with training through a web video that I could access anytime through my own computer or mobile device
			The VA provided an instruction sheet on My HealtheVet that I could read or print out
			Not sure
			Other
	ZZ2	I have heard of Secure Messaging but have not tried or have not been able to use it because: (Please select all that apply)	I did not understand what Secure Messaging is		Checkbox, one-up vertical	Multi	Y	Skip	SBLWhyNotUsed
			I have not signed up for a Premium My HealtheVet account. (Authenticated Account)
			I have a Premium My HealtheVet account, but did not know where to look for the Secure Messaging. (Authenticated Account)
			I am not interested in Secure Messaging
			I believe it will be too hard or time-consuming to use
			When I have a question or request that doesn't require a visit, I prefer to talk on the phone with my VA healthcare team
			I believe that the response that I may receive from my VA healthcare team would not fully address my information needs
			I feel uncertain about the privacy and security of my personal health information using Secure Messaging.
			I do not have regular access to a computer, smart phone or tablet
			Not sure/Do not recall
		In the past year, have you used My HealtheVet to accomplish any of the following tasks? (please select all that apply)	Use the Blue Button (Download My Data)		Checkbox, one-up vertical	Multi	Y		SPRMultiuse
			Refill my prescriptions
			View my medications information
			View my VA Notes (written by my health care team)
			View my lab or other test results
			View my VA Wellness Reminders
			Review my medical history (conditions, procedures, accidents and events)
			Research my health using education resources (for example, the My HealtheVet Medical Library)
			Enter data that I track myself such as weight, blood pressure, blood sugar, etc.
			Enter information about my non-VA medications or supplements
			None of the above
		How often do you find that information from the VA (in print or online) about your medical condition is difficult to understand?	Never or almost never		Drop down, select one	Single	Y		SANHlthLit
			Infrequently
			Occasionally
			Frequently
			Very frequently or always
			Not sure/Do not recall
RJB00029		My use of the My HealtheVet personal health record has improved my ability to manage my health.	Strongly agree		Drop down, select one	Single	Y		MHV improve Health
			Agree
			Not sure
			Disagree
			Strongly disagree
			Not applicable
		Overall, how confident are you that you could get health-related advice or information if you needed it by using a computer, smart phone or tablet (like an iPhone or iPad)?	Not at all confident		Drop down, select one	Single	Y		SANHlthSearch
			Somewhat confident
			Moderately confident
			Confident
			Very confident
			Not sure
CAS0029037		The My HealtheVet website provides articles on topics of interest to Veterans. What topics are you most interested in for upcoming articles?			Open-ended		N		OE_Articles
ALM0173		What is the main improvement that you would suggest for the My HealtheVet web site?			Open-ended	Single	N		One Improvement
CAS0029040		What additional services would you like to see on My HealtheVet? (Please select all that apply)	Schedule or change my VA appointments		Checkbox, one-up vertical	Multi	N		Additional Services
			Track the status of my prescription refill delivery
			View/pay my VA bills/copayments
			View a list of my VA health care providers and their contact information
			Use a mobile app for My HealtheVet
			Join an online forum to discuss health issues with other Veterans
			Advance check-in for my VA clinic visits
			Authorize sharing information I have stored in My HealtheVet with other people (e.g., family, caregiver)
			Authorize sharing information that I have stored in My HealtheVet with my VA health care team
			Authorize sharing information that I have stored in My HealtheVet with my Non-VA health care provider
			Check to determine if my different medications are safe when taken together
			More online educational programs
			Receive a monthly email newsletter
			Receive notification of new content/features on the site
			Other (please specify):	A
CAS0029041	A	Other - Services			Text area, no char limit	Single	N		OE_Other Services
AED06379		Have you completed this survey within the past 3 months?	Yes		Radio button, one-up vertical				Survey
			No			Single	N
			Don't recall

---

Sheet 11: Current Custom Qsts (9-16-13)

Err:509	Model Instance Name: VA - My HealtheVet			red & strike-through: DELETE
MID:	MID:	NJxFtMU9UosBkJZRd48x9Q==		underlined & italicized: RE-ORDER
Err:509				pink: ADDITION
Date:	Date:	6/23/2009		blue + -->: REWORDING
				violet (bold): SKIP-LOGIC
	MID: CUSTOM QUESTION LIST
QID	QID	Skip Logic Label	Question Text	Answer Choices (limited to 50 characters)	Skip to	Type (select from list)	Single or Multi	Required Y/N	Special Instructions	Question Label
1	ALM0170		Which of the following best describes you?	Active duty		Checkbox, one-up vertical	Multi	Y		Role
				National Guard/Reserve
				Veteran
				Family member of a veteran or Servicemember
				Caregiver of a Veteran or Servicemember (other than family)
				Veteran Service Organization member
				VA employee
				Non-VA federal government employee
				State/local government employee
				General public
				Other role
2	RJB00048		Please indicate your military period(s) of service:	Global War on Terror (OEF/OIF/OND)		Check-boxes	Multi	N		Military Service
				Desert Shield/Desert Storm
				Vietnam War
				Korean War
				World War II
				Peacetime Service
				Other
				Not Applicable
3	AED02714		What is your age range?	Under 20		Dropdown (Select-one)	Single	N		Age
				20-24
				25-29
				30-34
				35-39
				40-44
				45-49
				50-54
				55-59
				60-64
				65-69
				70-74
				75-79
				80-84
				85 or older
4	JIC00267		What is your gender?	Male		Dropdown (Select-one)	Single	N		Gender
				Female
5	CAS0028939		Which of the following best describes the highest level of education you have completed?	Did not complete high school		Radio button, one-up vertical	Single	Y		Education
				High school graduate
				Some college or vocational school
				College graduate
				Some postgraduate school
				Graduate or professional degree
6	JIC00178		In general, how would you rate your overall health?	Excellent		Dropdown (Select-one)	Single	Y		Overall Health
				Very Good
				Good
				Fair
				Poor
7	RJB00026		Are you a registered user on the MyHealtheVet web site?	Yes	A	Checkbox, one-up vertical	Single	Y	Skip Logic	Registered User
				No
				Not sure
8	CAS0028940	A	Your member log-in box now includes an icon for your account type. What type of My HealtheVet account do you have?	Basic (B)		Checkbox, one-up vertical	Single	Y	Skip Logic	User Type
				Advanced (A)
				Premium (authenticated or IPA’d)(P)
				Not sure
9	ALM0169		How frequently do you visit the My HealtheVet web site?	First time		Dropdown (Select-one)	Single	Y		Visit Frequency
				Daily
				More than once a day
				About once a week
				About once a month
				About every 6 months
				Less than every 6 months
10	RJB00022		What were you trying to accomplish today in My HealtheVet? (please select all that apply)			Checkbox, one-up vertical	Multi	Y		Reason
				Learn more about features that are available
				Request a prescription refill
				View my medication history
				Use Secure Messaging to communicate with my VA health care team
				Use the Blue Button (Download My Data)
				View my VA Appointments
				Look up information about a health condition or medication
				View my lab or other test results
				View my VA Wellness Reminders
				View my VA Notes (written by my health care team)
				Enter my personal information (emergency contacts, etc.)
				Enter data that I track myself such as weight, blood pressure, blood sugar, etc.
				Enter information about my non-VA medications or supplements
				Find a VA facility
				Find information about VA Health Benefits
				Find information about VA Benefits other than health benefits
				Other (please specify)	A
11	RJB00022other	A	Other - trying to accomplish			Text field, <100 char	Single	N
12	ALM0172		Did you accomplish what you wanted to in My HealtheVet?	Yes		Dropdown (Select-one)	Single	Y		Task Accomplishment
				No
				Partially
				Not finished yet
13	CAS0028943		Do you get care at a VA facility?	Yes	A,B	Checkbox, one-up vertical	Single	Y	Skip Logic	VA facility for Care
				No
				Not Sure
14	CAS0028944	A	In the past year, how often did you use a VA medical facility or service for your health care needs?	Never		Checkbox, one-up vertical	Single	N	skip logic	VA Facility frequency
				Once in the past year
				2 to 11 times in the past year
				12 or more times in the past year
15	CAS0028945	B	How much time does it take for you to travel to the nearest VA facility?	Less than 15 minutes		Checkbox, one-up vertical	single	N	skip logic	VA Facility Travel Time
				15 minutes to less than 1/2 hour
				1/2 hour to less than an hour
				An hour to less than 1 1/2 hours
				1 1/2 hours to less than two hours
				Two hours or more
				Not sure
NEW VA OPEN NOTES QUESTION ROTATION	NEW VA OPEN NOTES QUESTION ROTATION
16	CAS0028946		VA Notes written by providers and other members of the health care team since January 1, 2013 are now available to veterans with a Premium My HealtheVet account. Which best describes your knowledge about VA patients being able to view clinic and hospital visit notes (VA Notes) using the Blue Button. (Please choose one)	I knew that visit notes can be viewed by VA patients with a Premium Account		Radio button, one-up vertical	Single	Y		Open Notes Knowledge
				I didn’t know that visit notes can be viewed by VA patients with a Premium Account
				I’m not sure
17	CAS0028947		Which best describes your use of the VA Blue Button to access your visit notes (VA Notes)?	I viewed my visit notes using the Blue Button at least once	A	Radio button, one-up vertical	Single	Yes	Skip Logic	Visit notes
				I tried to view visit notes using Blue Button but was not able to do so	C, D
				I don’t have a Premium My HealtheVet account	D
				I don’t know what Blue Button is or have never used it	D
				I’m not sure	D
18	CAS0028948	A	What information from your VA health record have you viewed using the Blue Button in My HealtheVet? (Choose ALL that apply)	Visit notes from a clinic visit with a primary care provider (doctor, nurse practitioner or physician assistant)	B1 - B10	Radio button, one-up vertical	Multi	Yes	Skip Logic	VA Notes Info Viewed
				Visit notes from a clinic visit with a specialist (medical or surgical specialty)	B1-B10
				Visit notes from a mental health professional	B1-B10
				Notes from a hospital visit or stay (emergency room visit or discharge summary)	B1-B10
				VA Notes from Secure Messaging
				None of the above/ Don't remember	D1
19	CAS0028949	B1	Why did you read your visit notes (VA Notes)? (Check ALL that apply)	I did not read any visit notes (VA Notes)	D2	Radio button, one-up vertical				VA Notes Reason
				I tried to read my visit notes (VA Notes) but was not able to	C1, D2
				I was curious
				I wanted to remember what happened in the visit
				I wanted to know more about my health
				I wanted to check the notes to see if they were right
				I wanted to be sure I understood what my provider (or other member of the health care team) said
				I wanted to know what my provider (or other member of the health care team) was thinking
				Other reason (please explain)	B1A
20	CAS0028935	B1A	Other - reason read VA Notes			Text area, no char limit		N	Skip Logic	VA Notes OE_Reason read
21	CAS0028956	B2	What did you do with your notes (VA Notes) using the Blue Button? (Check ALL that apply)	I read it		Radio button, one-up vertical	Multi	Y	Skip Logic	VA Notes Use
				I printed it
				I downloaded it to keep a copy for myself
				I shared it with a family member, relative or friend who helps take care of me
				I discussed it with a VA provider or other health care team member
				I shared it with a health care provider outside of VA
				Other, please explain	B2A
				I don’t remember
22	CAS0028957	B2A	Other - What you did with your notes			Text area, no char limit		N	Skip	VA Notes OE_Other Use
23	CAS0028958	B3	Did you talk to or contact your provider or health care team about the notes (VA Notes), or have a plan to do so? (Choose one)	No, I did not talk to or contact my provider or health care team about the notes	B3A	Radio button, one-up vertical	Single	Y	Skip	VA Notes Contact
				I plan to contact my provider or health care team about the notes	B3B
				Yes, I did contact my provider or health care team about the notes	B3B
24	CAS0028952	B3A	If you did not contact or don’t plan to contact your provider or health care team, why not? (Check all that apply)	I had no reason to contact my provider or health care team about the notes		Radio button, one-up vertical	Multi	Y	Skip Logic	VA Notes Did not Contact
				I didn’t think it was important
				I didn’t want to waste my provider or health care team’s time
				I didn’t want my provider or health care team to be upset with me
				I did not feel I knew enough to talk with my doctor about my concerns
				It was too much of a bother for me
				Other reason (please explain)	B3AA
25	CAS0028953	B3AA	Other - reason did not contact			Text area, no char limit		N		VA Notes OE_Did not contact
26	CAS0028954	B3B	Why did you contact, or plan to contact, your provider or health care team about the notes (VA Notes)? (Check all that apply)	To get an explanation about something in the note		Radio button, one-up vertical	Multi	Y	Skip	VA Notes Did Contact
				To learn more about my health issue, medications or test results
				To discuss something I was worried about in the note
				To discuss something that I thought was not correct in the note
				To ask about removing or changing something in the note
				Other reason (please explain)	B3BA
27	CAS0028955	B3BA	Other - reason did contact			Text field, <100 char		N	skip	VA Notes Did Contact OE
28	CAS0028976	B4	Please think about what it is like to access and view the visit notes (VA Notes) written by your provider and health care team using the Blue Button “Download My Data” on My HealtheVet.   How easy is it to find the visit notes (VA Notes) using the Blue Button “Download My Data” on My HealtheVet?	Very hard		Radio button, one-up vertical	Single	Y	Skip	VA Notes Access
				Somewhat hard
				Somewhat easy
				Very easy
				I don’t know
29	CAS0028977	B5	The display of my visit notes (VA Notes) is easy to read.	Disagree		Radio button, one-up vertical	Single	Y	Skip	VA Notes Display
				Somewhat disagree
				Somewhat agree
				Agree
				I don’t know
30	CAS0028959	B6	What information were you trying to find in your visit notes (VA Notes)? (Check all that apply):	I’m not sure what I was looking for			Multi	Y	Skip	VA notes Trying to find
				The note written by a provider or health care team after a clinic visit
				The note written by a provider or health care team after an emergency room visit
				The note written by a provider or health care team after a hospital stay
				What my provider or health care team thinks about my health issues
				Changes that were discussed during a visit
				Recommendations or treatment advice from my provider or health care team
				When I’m supposed to come back for my next appointment
				A referral to a specialist or for further testing
				Other, please explain	B6A
31	CAS0028960	B6A	Other- information trying to find in my visit notes			Text area, no char limit		N		VA Notes OE_ Trying to find
32	CAS0028961	B7	I did not understand the information in my VA Notes (for example, there were too many abbreviations, acronyms or words I did not understand).	Disagree		Radio button, one-up vertical	Single	Y	skip	VA Notes not understand
				Somewhat disagree
				Somewhat agree
				Agree
				I don’t know
33	CAS0028962	B8	In your opinion, how much do the visit notes (VA notes) correctly describe your clinic or hospital visit?	Notes don’t describe the visit correctly		Radio button, one-up vertical	single	Y	Skip	VA Notes Opinion
				Notes mostly describe the visit correctly
				Notes describe the visit pretty well
				I don't know
34	CAS0028963	B9	There is too much information in my visit notes (VA notes).	Disagree		Radio button, one-up vertical	Single	Y	skip	VA notes Level of Information
				Somewhat disagree
				Somewhat agree
				Agree
				I don’t know
35	CAS0029000	B10	What is your overall satisfaction with access to your visit notes using Blue Button? Select a number from 1 to 10, with 1 the lowest and 10 the highest level of satisfaction.	1=Not at all Satisfied		Radion button, scale, no don't know	Single	Y	Skip	VA Notes Satisfaction Level
				2
				3
				4
				5	Matthew Castillo: Somewhat satisfied was removed just due to technological implications on the backend.
				6
				7
				8
				9
				Extremely Satisfied=10
Attempters ONLY	Attempters ONLY
36	CAS0028964	C	Why do you think you were not able to view your notes (VA Notes)? (Check all that apply)	I couldn’t figure out where to look for the visit notes		Checkbox, one-up vertical	Multi	Yes	Skip Logic	VA Notes Unable to view
				It’s too hard to use the Blue Button feature
				I requested the notes, but the Blue Button feature was updating my information
				I was looking for notes that were written before January 1, 2013
				I tried to get the notes before they were available to me (7 days after a note is completed)
				I don’t know why
				Other reason ( please explain)	CA
37	CAS0028965	CA	Other- reason I was unable to view my VA Notes:			Text area, no char limit		N	Skip Logic	VA Notes OE_unable to view
38	CAS0028933	C1	Why do you think you were not able to view your notes (VA Notes)? (Check all that apply)	I couldn’t figure out where to look for the visit notes		Checkbox, one-up vertical	Multi	Yes	Skip Logic	VA Notes Unable to view1
				It’s too hard to use the Blue Button feature
				I requested the notes, but the Blue Button feature was updating my information
				I was looking for notes that were written before January 1, 2013
				I tried to get the notes before they were available to me (7 days after a note is completed)
				I don’t know why
				Other reason ( please explain)	CA
39	CAS0028934	CA1	Other- reason I was unable to view my VA Notes:			Text area, no char limit		N	Skip Logic	VA Notes OE_unable to view1
NON USERS and Attempters ONLY	NON USERS and Attempters ONLY
40	CAS0029002	D	If you were to look at your visit notes from your VA health record, which information would most interest you? (Choose all that apply)	Visit notes from a clinic visit with a primary care provider (doctor, nurse practitioner or physician assistant)		Radio button, one-up vertical	Multi	Y	Skip Logic	VA Notes_info Would Like
				Visit notes from a clinic visit with a specialist (medical or surgical specialty)
				Visit notes from a mental health professional
				Notes from a hospital visit or stay (emergency room visit or discharge summary
				Laboratory test results (blood, urine or other lab test)
				Radiology test results (X-ray, MRI, ultrasound or other imaging test)
				Problem list (conditions or diagnoses)
				Other (please explain)	DA
				I don’t know
41	CAS0029003	DA	Other- most interested in visit notes			Text area, no char limit		N		VA Notes OE_Would Like
42	CAS0028966	D1	If you were to look at your visit notes from your VA health record, which information would most interest you? (Choose all that apply)	Visit notes from a clinic visit with a primary care provider (doctor, nurse practitioner or physician assistant)		Checkbox, one-up vertical	Multi	Y	Skip Logic	VA Notes_info Would Like1
				Visit notes from a clinic visit with a specialist (medical or surgical specialty)
				Visit notes from a mental health professional
				Notes from a hospital visit or stay (emergency room visit or discharge summary
				Laboratory test results (blood, urine or other lab test)
				Radiology test results (X-ray, MRI, ultrasound or other imaging test)
				Problem list (conditions or diagnoses)
				Other (please explain)	DA
				I don’t know
43	CAS0029001	DA1	Other- most interested in visit notes			Text area, no char limit		N		VA Notes OE_Would Like1
44	CAS0028950	D2	If you were to look at your visit notes from your VA health record, which information would most interest you? (Choose all that apply)	Visit notes from a clinic visit with a primary care provider (doctor, nurse practitioner or physician assistant)		Checkbox, one-up vertical	Multi	Y	Skip Logic	VA Notes_info Would Like2
				Visit notes from a clinic visit with a specialist (medical or surgical specialty)
				Visit notes from a mental health professional
				Notes from a hospital visit or stay (emergency room visit or discharge summary
				Laboratory test results (blood, urine or other lab test)
				Radiology test results (X-ray, MRI, ultrasound or other imaging test)
				Problem list (conditions or diagnoses)
				Other (please explain)	DA
				I don’t know						VA Notes OE_Would Like2
45	CAS0028951	DA2	Other- most interested in visit notes			Text area, no char limit		N
CAS0028967	CAS0028967		We would like to ask you about how you think viewing your visit notes (VA Notes) might help you with your health and your health care. Think about how notes help you now, or, if you have not yet viewed your notes, how visit notes might help you in the future.17. Visit notes (VA Notes) will help me understand my health and medical conditions better.	Disagree		Radio button, one-up vertical	single	Y		VA Notes Future Help
				Somewhat disagree
				Somewhat agree
				Agree
				I don’t know
CAS0028968	CAS0028968		Visit notes will help me remember the plan for my care better.	Disagree		Radio button, one-up vertical	single	Y		VA Notes Remember plan for care
				Somewhat disagree
				Somewhat agree
				Agree
				I don’t know
CAS0028969	CAS0028969		Visit notes will help me take better care of myself.	Disagree		Radio button, one-up vertical	single	Y		VA Notes Better Care of Self
				Somewhat disagree
				Somewhat agree
				Agree
				I don’t know
CAS0029016	CAS0029016		Visit notes will help me do a better job taking my medications as prescribed.	Disagree		Radio button, one-up vertical	Single	y		VA Note Better care of Meds
				Somewhat disagree
				Somewhat agree
				Agree
				I don’t know
				I don’t take any medications
CAS0029017	CAS0029017		Visit notes will make me feel more in control of my health care.	Disagree		Radio button, one-up vertical	Single	Y		VA Notes More in control
				Somewhat disagree
				Somewhat agree
				Agree
				I don’t know
CAS0029018	CAS0029018		Visit notes will make me worry more.	Disagree		Radio button, one-up vertical	Single	Y		VA notes Worry
				Somewhat disagree
				Somewhat agree
				Agree
				I don’t know
CAS0028970	CAS0028970		Visit notes will help me be better prepared for clinic visits.	Disagree		Radio button, one-up vertical	Single	Y		VA Notes Prepared
				Somewhat disagree
				Somewhat agree
				Agree
				I don’t know
CAS0028971	CAS0028971		Visit notes will be more confusing than helpful.	Disagree		Radio button, one-up vertical	Single	Y		VA Notes Confusing
				Somewhat disagree
				Somewhat agree
				Agree
				I don’t know
CAS0028972	CAS0028972		I think viewing visit notes will change how I feel about my provider or health care team	Disagree		Radio button, one-up vertical	Single	Y		VA Notes Change View
				Somewhat disagree
				Somewhat agree
				Agree
				I don’t know
CAS0028973	CAS0028973		In the past, have you ever requested a copy of your medical records from a VA facility?	Yes		Radio button, one-up vertical	Single	Y		Medical Records Request
				No
CAS0028974	CAS0028974		I would like to be able to add comments to my VA Notes.	Disagree		Radio button, one-up vertical	single	Y		VA Notes add comments
				Somewhat disagree
				Somewhat agree
				Agree
				Don’t know
CAS0028975	CAS0028975		Do you think that you will use the Blue Button to access your visit notes in the future?	I will NOT use it in the future		Radio button, one-up vertical	Single	Y		VA Notes Blue Button use Future
				I might use it in the future.
				I will definitely use it in the future
CAS0029036	CAS0029036		Do you ‘follow’ your local VA medical center on Facebook?	Yes		Radio button, one-up vertical	Single	Y		Facebook
				No, I don’t use Facebook
				No, I do use Facebook but have not ‘followed’ my VA medical center page
RJB00029	RJB00029		My use of the My HealtheVet personal health record has improved my ability to manage my health.	Strongly agree		Drop down, select one	Single	Y		MHV improve Health
				Agree
				Not sure
				Disagree
				Strongly disagree
				Not applicable
CAS0029037	CAS0029037		The My HealtheVet website provides articles on topics of interest to Veterans. What topics are you most interested in for upcoming articles?			Open-ended		N		OE_Articles
CAS0029038	CAS0029038		Have you discussed your My HealtheVet Personal Health Record with any of the following people? Please check all that apply:	My VA health care provider		Checkbox, one-up vertical	Multi	N		Discussed Health Care
				My non-VA healthcare provider(s)
				My family, friends, or caregiver(s)
				Veterans I know
				Other (please specify)	A
				I have not discussed My HealtheVet Personal Health Record with others
CAS0029039	CAS0029039	A	I have discussed my My HealtheVet Personal Health Record with:			Text field, <100 char		N		OE_Discussed medical records
ALM0173	ALM0173		What is the main improvement that you would suggest for the My HealtheVet web site?			Open-ended	Single	N		One Improvement
CAS0029040	CAS0029040		What additional services would you like to see on My HealtheVet? (Please select all that apply)	Schedule or change my VA appointments		Checkbox, one-up vertical	Multi	N		Additional Services
				Track the status of my prescription refill delivery
				View/pay my VA bills/copayments
				View a list of my VA health care providers and their contact information
				Use a mobile app for My HealtheVet
				Join an online forum to discuss health issues with other Veterans
				Advance check-in for my VA clinic visits
				Authorize sharing information I have stored in My HealtheVet with other people (e.g., family, caregiver)
				Authorize sharing information that I have stored in My HealtheVet with my VA health care team
				Authorize sharing information that I have stored in My HealtheVet with my Non-VA health care provider
				Check to determine if my different medications are safe when taken together
				More online educational programs
				Receive a monthly email newsletter
				Receive notification of new content/features on the site
				Other (please specify):	A
CAS0029041	CAS0029041	A	Other - Services			Text area, no char limit	Single	N		OE_Other Services
CAS0029042	CAS0029042		Are you aware that there is a My HealtheVet Coordinator at each VA Medical Center to assist with questions, concerns, and outreach for My HealtheVet?	Yes		Radio button, one-up vertical	Single	Y		MHV Coordinator Awareness
				No
CAS0029043	CAS0029043		Have you contacted the My HealtheVet Help Desk in the past 3 months?	Yes	A,B	Radio button, one-up vertical	Single	Yes	Skip Logic	Help Desk
				No
				Do not recall
CAS0029044	CAS0029044	A	How was that experience?	Excellent		Radio button, one-up vertical	single	y	skip logic	Help Desk Rating
				Very Good
				Good
				Fair
				Poor
CAS0029045	CAS0029045	B	Was your question, issue, or concern resolved?	Yes		Radio button, one-up vertical	single	y	skip logic	Help Desk Resolution
				No
				Partially
				Not Sure
AED06379	AED06379		Have you completed this survey within the past 3 months?	Yes		Radio button, one-up vertical				Survey
				No			Single	N
				Don't recall

---

Sheet 12: Current Custom Qsts (5-9-13)

Model Instance Name: VA - My HealtheVet			red & strike-through: DELETE
MID:	NJxFtMU9UosBkJZRd48x9Q==		underlined & italicized: RE-ORDER
			pink: ADDITION
Date:	6/23/2009		blue + -->: REWORDING
			violet (bold): SKIP-LOGIC
MID: CUSTOM QUESTION LIST
QID	Skip Logic Label	Question Text	Answer Choices (limited to 50 characters)	Skip to	Type (select from list)	Single or Multi	Required Y/N	Special Instructions	Question Label
ALM0170		Which of the following best describes you?	Active duty		Checkbox, one-up vertical	Multi	Y		Role
			National Guard/Reserve
			Veteran
			Family member of a veteran or Servicemember
			Caregiver of a Veteran or Servicemember (other than family)
			Veteran Service Organization member
			VA employee
			Non-VA federal government employee
			State/local government employee
			News media
			General public
			Federal government employee
			Other role
RJB00048		Please indicate your military period(s) of service:	Global War on Terror (OEF/OIF/OND)		Check-boxes	Multi	N		Military Service
			Desert Shield/Desert Storm
			Vietnam War
			Korean War
			World War II
			Peacetime Service
			Other
			Not Applicable
AED02714		What is your age range?	Under 20		Dropdown (Select-one)	Single	N		Age
			20-24
			25-29
			30-34
			35-39
			40-44
			45-49
			50-54
			55-59
			60-64
			65-69
			70-74
			75-79
			80-84
			85 or older
JIC00267		What is your gender?	Male		Dropdown (Select-one)	Single	N		Gender
			Female
		Which of the following best describes the highest level of education you have completed?	Did not complete high school		Radio button, one-up vertical	Single	Y		Education
			High school graduate
			Some college or vocational school
			College graduate
			Some postgraduate school
			Graduate or professional degree
JIC00178		In general, how would you rate your overall health?	Excellent		Dropdown (Select-one)	Single	Y		Overall Health
			Very Good
			Good
			Fair
			Poor
RJB00026		Are you a registered user on the MyHealtheVet web site?	Yes	A	Checkbox, one-up vertical	Single	Y	Skip Logic	Registered User
			No
			Not sure
	A	Your member log-in box now includes an icon for your account type. What type of My HealtheVet account do you have?	Basic (B)		Checkbox, one-up vertical	Single	Y	Skip Logic	User Type
			Advanced (A)
			Premium (authenticated or IPA’d)(P)
			Not sure
ALM0169		How frequently do you visit the My HealtheVet web site?	First time		Dropdown (Select-one)	Single	Y		Visit Frequency
			Daily
			More than once a day
			About once a week
			About once a month
			About every 6 months
			Less than every 6 months
RJB00022		What were you trying to accomplish today in My HealtheVet? (please select all that apply)	Enter/keep track of personal information (My Caregivers, etc.)		Checkbox, one-up vertical	Multi	Y		Reason
			-->Learn more about what features that are available
			Request a prescription refill
			View my medication history
			Use Secure Messaging to communicate with my VA health care team
			Download my data using the VA Blue Button _x000D_-->Use the Blue Button (Download My Data)
			View my VA Appointments
			Look up information about a health condition or medication
			View my lab or other test results
			View my VA Wellness Reminders
			View my VA Notes (written by my health care team)
			Enter my personal information (emergency contacts, etc.)
			Enter data that I track myself such as weight, blood pressure, blood sugar, etc.
			Enter information about my non-VA medications or supplements
			-->Find a VA health care facility
			Find information about VA Health Benefits
			Find information about VA Benefits other than health benefits
			Enter/keep track of personal health care information (blood pressure, blood sugar, etc.)
			Look up information about a medication
			Access prescription history from my VA medical record
			Secure message a provider
			View lab results
			Research a health condition
			Find information about VA Benefits
			Other (please specify)	A
RJB00022other	A	Other - trying to accomplish			Text field, <100 char	Single	N
ALM0172		Did you accomplish what you wanted to in My HealtheVet?	Yes		Dropdown (Select-one)	Single	Y		Task Accomplishment
			No
			Partially
			Not finished yet
		Do you get care at a VA facility?	Yes	A,B	Checkbox, one-up vertical	Single	Y	Skip Logic	VA facility for Care
			No
			Not Sure
	A	In the past year, how often did you use a VA medical facility or service for your health care needs?	Never		Checkbox, one-up vertical	Single	N	skip logic	VA Facility frequency
			Once in the past year
			2 to 11 times in the past year
			12 or more times in the past year
	B	How much time does it take for you to travel to the nearest VA facility?	Less than 15 minutes		Checkbox, one-up vertical	single	N	skip logic	VA Facility Travel Time
			15 minutes to less than 1/2 hour
			1/2 hour to less than an hour
			An hour to less than 1 1/2 hours
			1 1/2 hours to less than two hours
			Two hours or more
			Not sure
NEW VA OPEN NOTES QUESTION ROTATION
		VA Notes written by providers and other members of the health care team since January 1, 2013 are now available to veterans with a Premium My HealtheVet account. Which best describes your knowledge about VA patients being able to view clinic and hospital visit notes (VA Notes) using the Blue Button. (Please choose one)	I knew that visit notes can be viewed by VA patients with a Premium Account		Radio button, one-up vertical	Single	Y		Open Notes Knowledge
			I didn’t know that visit notes can be viewed by VA patients with a Premium Account
			I’m not sure
		Which best describes your use of the VA Blue Button to access your visit notes (VA Notes)?	I viewed my visit notes using the Blue Button at least once	A	Checkbox, one-up vertical	Single	Yes	Skip Logic	Visit notes
			I tried to view visit notes using Blue Button but was not able to do so	C, D
			I don’t have a Premium My HealtheVet account	D
			I don’t know what Blue Button is or have never used it	D
			I’m not sure	D
	A	What information from your VA health record have you viewed using the Blue Button in My HealtheVet? (Choose ALL that apply)	Visit notes from a clinic visit with a primary care provider (doctor, nurse practitioner or physician assistant)	B1 - B10	Checkbox, one-up vertical	Multi	Yes	Skip Logic	VA Notes Info Viewed
			Visit notes from a clinic visit with a specialist (medical or surgical specialty)	B1-B10
			Visit notes from a mental health professional	B1-B10
			Notes from a hospital visit or stay (emergency room visit or discharge summary)	B1-B10
			VA Notes from Secure Messaging
			None of the above/ Don't remember	D
	B1	Why did you read your visit notes (VA Notes)? (Check ALL that apply)	I did not read any visit notes (VA Notes)	D	Checkbox, one-up vertical				VA Notes Reason
			I tried to read my visit notes (VA Notes) but was not able to	C, D
			I was curious
			I wanted to remember what happened in the visit
			I wanted to know more about my health
			I wanted to check the notes to see if they were right
			I wanted to be sure I understood what my provider (or other member of the health care team) said
			I wanted to know what my provider (or other member of the health care team) was thinking
			Other reason (please explain)	B1A
	B1A	Other - reason read VA Notes			Text area, no char limit		N	Skip Logic	VA Notes OE_Reason read
	B2	What did you do with your notes (VA Notes) using the Blue Button? (Check ALL that apply)	I read it		Checkbox, one-up vertical	Multi	Y	Skip Logic	VA Notes Use
			I printed it
			I downloaded it to keep a copy for myself
			I shared it with a family member, relative or friend who helps take care of me
			I discussed it with a VA provider or other health care team member
			I shared it with a health care provider outside of VA
			Other, please explain	B2A
			I don’t remember
	B2A	Other - What you did with your notes			Text area, no char limit		N	Skip	VA Notes OE_Other Use
	B3	Did you talk to or contact your provider or health care team about the notes (VA Notes), or have a plan to do so? (Choose one)	No, I did not talk to or contact my provider or health care team about the notes	B3A	Checkbox, one-up vertical	Single	Y	Skip	VA Notes Contact
			I plan to contact my provider or health care team about the notes	B3B
			Yes, I did contact my provider or health care team about the notes	B3B
	B3A	If you did not contact or don’t plan to contact your provider or health care team, why not? (Check all that apply)	I had no reason to contact my provider or health care team about the notes		Checkbox, one-up vertical	Multi	Y	Skip Logic	VA Notes Did not Contact
			I didn’t think it was important
			I didn’t want to waste my provider or health care team’s time
			I didn’t want my provider or health care team to be upset with me
			I did not feel I knew enough to talk with my doctor about my concerns
			It was too much of a bother for me
			Other reason (please explain)	B3AA
	B3AA	Other - reason did not contact			Text area, no char limit		N		VA Notes OE_Did not contact
	B3B	Why did you contact, or plan to contact, your provider or health care team about the notes (VA Notes)? (Check all that apply)	To get an explanation about something in the note		Checkbox, one-up vertical	Multi	Y	Skip	VA Notes Did Contact
			To learn more about my health issue, medications or test results
			To discuss something I was worried about in the note
			To discuss something that I thought was not correct in the note
			To ask about removing or changing something in the note
			Other reason (please explain)	B3BA
	B3BA	Other - reason did contact			Text field, <100 char		N	skip	VA Notes Did Contact OE
	B4	Please think about what it is like to access and view the visit notes (VA Notes) written by your provider and health care team using the Blue Button “Download My Data” on My HealtheVet.   How easy is it to find the visit notes (VA Notes) using the Blue Button “Download My Data” on My HealtheVet?	Very hard		Checkbox, one-up vertical	Single	Y	Skip	VA Notes Access
			Somewhat hard
			Somewhat easy
			Very easy
			I don’t know
	B5	The display of my visit notes (VA Notes) is easy to read.	Disagree		Checkbox, one-up vertical	Single	Y	Skip	VA Notes Display
			Somewhat disagree
			Somewhat agree
			Agree
			I don’t know
	B6	What information were you trying to find in your visit notes (VA Notes)? (Check all that apply):	I’m not sure what I was looking for			Multi	Y	Skip	VA notes Trying to find
			The note written by a provider or health care team after a clinic visit
			The note written by a provider or health care team after an emergency room visit
			The note written by a provider or health care team after a hospital stay
			What my provider or health care team thinks about my health issues
			Changes that were discussed during a visit
			Recommendations or treatment advice from my provider or health care team
			When I’m supposed to come back for my next appointment
			A referral to a specialist or for further testing
			Other, please explain	B6A
	B6A	Other- information trying to find in my visit notes			Text area, no char limit		N		VA Notes OE_ Trying to find
	B7	I did not understand the information in my VA Notes (for example, there were too many abbreviations, acronyms or words I did not understand).	Disagree		Checkbox, one-up vertical	Single	Y	skip	VA Notes not understand
			Somewhat disagree
			Somewhat agree
			Agree
			I don’t know
	B8	In your opinion, how much do the visit notes (VA notes) correctly describe your clinic or hospital visit?	Notes don’t describe the visit correctly		Checkbox, one-up vertical	single	Y	Skip	VA Notes Opinion
			Notes mostly describe the visit correctly
			Notes describe the visit pretty well
			I don't know
	B9	There is too much information in my visit notes (VA notes).	Disagree		Checkbox, one-up vertical	Single	Y	skip	VA notes Level of Information
			Somewhat disagree
			Somewhat agree
			Agree
			I don’t know
	B10	What is your overall satisfaction with access to your visit notes using Blue Button? Select a number from 1 to 10, with 1 the lowest and 10 the highest level of satisfaction.	1=Not at all Satisfied		Radion button, scale, no don't know	Single	Y	Skip	VA Notes Satisfaction Level
			2
			3
			4
			5 = Somewhat Satisfied
			6
			7
			8
			9
			10 - Extremely Satisfied
Attempters ONLY
	C	Why do you think you were not able to view your notes (VA Notes)? (Check all that apply)	I couldn’t figure out where to look for the visit notes		Checkbox, one-up vertical	Multi	Yes	Skip Logic	VA Notes Unable to view
			It’s too hard to use the Blue Button feature
			I requested the notes, but the Blue Button feature was updating my information
			I was looking for notes that were written before January 1, 2013
			I tried to get the notes before they were available to me (7 days after a note is completed)
			I don’t know why
			Other reason ( please explain)	CA
	CA	Other- reason I was unable to view my VA Notes:			Text area, no char limit		N	Skip Logic	VA Notes OE_unable to view
NON USERS and Attempters ONLY
	D	If you were to look at your visit notes from your VA health record, which information would most interest you? (Choose all that apply)	Visit notes from a clinic visit with a primary care provider (doctor, nurse practitioner or physician assistant)		Checkbox, one-up vertical	Multi	Y	Skip Logic	VA Notes_info Would Like
			Visit notes from a clinic visit with a specialist (medical or surgical specialty)
			Visit notes from a mental health professional
			Notes from a hospital visit or stay (emergency room visit or discharge summary
			Laboratory test results (blood, urine or other lab test)
			Radiology test results (X-ray, MRI, ultrasound or other imaging test)
			Problem list (conditions or diagnoses)
			Other (please explain)	DA
			I don’t know						VA Notes OE_Would Like
	DA	Other- most interested in visit notes			Text area, no char limit		N
		We would like to ask you about how you think viewing your visit notes (VA Notes) might help you with your health and your health care. Think about how notes help you now, or, if you have not yet viewed your notes, how visit notes might help you in the future.17. Visit notes (VA Notes) will help me understand my health and medical conditions better.	Disagree		Radio button, one-up vertical	single	Y		VA Notes Future Help
			Somewhat disagree
			Somewhat agree
			Agree
			I don’t know
		Visit notes will help me remember the plan for my care better.	Disagree		Radio button, one-up vertical	single	Y		VA Notes Remember plan for care
			Somewhat disagree
			Somewhat agree
			Agree
			I don’t know
		Visit notes will help me take better care of myself.	Disagree		Radio button, one-up vertical	single	Y		VA Notes Better Care of Self
			Somewhat disagree
			Somewhat agree
			Agree
			I don’t know
		Visit notes will help me do a better job taking my medications as prescribed.	Disagree		Radio button, one-up vertical	Single	y		VA Note Better care of Meds
			Somewhat disagree
			Somewhat agree
			Agree
			I don’t know
			I don’t take any medications
		Visit notes will make me feel more in control of my health care.	Disagree		Radio button, one-up vertical	Single	Y		VA Notes More in control
			Somewhat disagree
			Somewhat agree
			Agree
			I don’t know
		Visit notes will make me worry more.	Disagree		Radio button, one-up vertical	Single	Y		VA notes Worry
			Somewhat disagree
			Somewhat agree
			Agree
			I don’t know
		Visit notes will help me be better prepared for clinic visits.	Disagree		Radio button, one-up vertical	Single	Y		VA Notes Prepared
			Somewhat disagree
			Somewhat agree
			Agree
			I don’t know
		Visit notes will be more confusing than helpful.	Disagree		Radio button, one-up vertical	Single	Y		VA Notes Confusing
			Somewhat disagree
			Somewhat agree
			Agree
			I don’t know
		I think viewing visit notes will change how I feel about my provider or health care team	Disagree		Radio button, one-up vertical	Single	Y		VA Notes Change View
			Somewhat disagree
			Somewhat agree
			Agree
			I don’t know
		In the past, have you ever requested a copy of your medical records from a VA facility?	Yes		Radio button, one-up vertical	Single	Y		Medical Records Request
			Notes from a hospital visit or stay (emergency room visit or discharge summary
		I would like to be able to add comments to my VA Notes.	Disagree		Radio button, one-up vertical	single	Y		VA Notes add comments
			Somewhat disagree
			Somewhat agree
			Agree
			Don’t know
		Do you think that you will use the Blue Button to access your visit notes in the future?	I will NOT use it in the future		Radio button, one-up vertical	Single	Y		VA Notes Blue Button use Future
			I might use it in the future.
			I will definitely use it in the future
		Do you ‘follow’ your local VA medical center on Facebook?	Yes		Radio button, one-up vertical	Single	Y		Facebook
			No, I don’t use Facebook
			No, I do use Facebook but have not ‘followed’ my VA medical center page
RJB00029		My use of the My HealtheVet personal health record has improved my ability to manage my health.	Strongly agree		Drop down, select one	Single	Y		MHV improve Health
			Agree
			Not sure
			Disagree
			Strongly disagree
			Not applicable
		The My HealtheVet website provides articles on topics of interest to Veterans. What topics are you most interested in for upcoming articles?			Open-ended		N		OE_Articles
		Have you discussed your My HealtheVet Personal Health Record with any of the following people? Please check all that apply:	My VA health care provider		Checkbox, one-up vertical	Multi	N		Discussed Health Care
			My non-VA healthcare provider(s)
			My family, friends, or caregiver(s)
			Veterans I know
			Other (please specify)	A
			I have not discussed My HealtheVet Personal Health Record with others
	A	I have discussed my My HealtheVet Personal Health Record with:			Text field, <100 char		N		OE_Discussed medical records
ALM0173		What is the main improvement that you would suggest for the My HealtheVet web site?			Open-ended	Single	N		One Improvement
		What additional services would you like to see on My HealtheVet? (Please select all that apply)	Schedule or change my VA appointments		Checkbox, one-up vertical	Multi	N		Additional Services
			Track the status of my prescription refill delivery
			View/pay my VA bills/copayments
			View a list of my VA health care providers and their contact information
			Use a mobile app for My HealtheVet
			Join an online forum to discuss health issues with other Veterans
			Advance check-in for my VA clinic visits
			Authorize sharing information I have stored in My HealtheVet with other people (e.g., family, caregiver)
			Authorize sharing information that I have stored in My HealtheVet with my VA health care team
			Authorize sharing information that I have stored in My HealtheVet with my Non-VA health care provider
			Check to determine if my different medications are safe when taken together
			More online educational programs
			Receive a monthly email newsletter
			Receive notification of new content/features on the site
			Other (please specify):	A
	A	Other - Services			Text area, no char limit	Single	N		OE_Other Services
		Are you aware that there is a My HealtheVet Coordinator at each VA Medical Center to assist with questions, concerns, and outreach for My HealtheVet?	Yes		Radio button, one-up vertical	Single	Y		MHV Coordinator Awareness
			No
		Have you contacted the My HealtheVet Help Desk in the past 3 months?	Yes	A,B	Checkbox, one-up vertical	Single	Yes	Skip Logic	Help Desk
			No
			Do not recall
	A	How was that experience?	Excellent		Checkbox, one-up vertical	single	y	skip logic	Help Desk Rating
			Very Good
			Good
			Fair
			Poor
	B	Was your question, issue, or concern resolved?	Yes		Checkbox, one-up vertical	single	y	skip logic	Help Desk Resolution
			No
			Partially
			Not Sure
AED06379		Have you completed this survey within the past 3 months?	Yes		Radio button, one-up vertical				Survey
			No			Single	N
			Don't recall
RJB00027		Have you visited your VA Facility in person to show your ID and be "in-person authenticated" (IPA) for My HealtheVet?	Yes		Dropdown (Select-one)	Single	Y
			No
			Not sure
			Not applicable
EDO07291		Did you use a VA medical facility or service for any of your health care needs in the last 12 months?	Yes		Dropdown (Select-one)	Single	Y
			No
ACQLiv0018816		Please rate the clarity of the wording on this site.	1=Poor		Radio button, scale, has don't know	S	Y		Clear
			2
			3
			4
			5
			6
			7
			8
			9
			Excellent=10
			Don't know
ACQLiv0018817		Please rate how well you understand the wording on this site.	1=Poor		Radio button, scale, has don't know	S	Y		Understandable
			2
			3
			4
			5
			6
			7
			8
			9
			Excellent=10
			Don't know
ACQLiv0018818		Please rate the site on its use of short, clear sentences.	1=Poor		Radio button, scale, has don't know	S	Y		Concise
			2
			3
			4
			5
			6
			7
			8
			9
			Excellent=10
			Don't know
CJI0298		Do you have any of the following health problems? (check all that apply)	Prefer not to answer		Checkbox, one-up vertical	Multi	Y		Health Problems
			Diabetes
			High Blood Pressure
			High Cholesterol
			Heart Disease
			Previous Heart Attack
			Heart Failure
			Lung Disease/Asthma
			Spinal Cord Injury
			Arthritis of any kind
			Cancer
			Mental Health Problems
			Orthopedic Problems
			Ulcer or Stomach Disease
			Pain
			Anemia or other Blood Disease
			None of the above
CJI0299		Please rate your ability in using the Internet:	Beginner or novice (just starting/don't use Internet much)		Radio button, one-up vertical	Single	Y		Internet Ability
			Intermediate (use the Internet for a few things)
			Advanced (frequently use Internet & search for information)

---

Sheet 13: Current Custom Qsts (4-9-13)

Model Instance Name: VA - My HealtheVet			red & strike-through: DELETE
MID:	NJxFtMU9UosBkJZRd48x9Q==		underlined & italicized: RE-ORDER
			pink: ADDITION
Date:	6/23/2009		blue + -->: REWORDING
			violet (bold): SKIP-LOGIC
MID: CUSTOM QUESTION LIST
QID	Skip Logic Label	Question Text	Answer Choices (limited to 50 characters)	Skip to	Type (select from list)	Single or Multi	Required Y/N	Question Label
ALM0169		How frequently do you visit the My HealtheVet web site?	First time		Dropdown (Select-one)	Single	Y
			Daily
			More than once a day
			About once a week
			About once a month
			About every 6 months
			Less than every 6 months
ALM0170		Which of the following best describes you?	Active duty		Checkbox, one-up vertical	Multi	Y
			Veteran
			Family member of a veteran
			Veteran service organization
			News media
			General public
			VA employee
			Federal government employee
			State/local government employee
			Other role
RJB00048		Please indicate your military period(s) of service:	Global War on Terror (OEF/OIF)		Check-boxes	Multi	N
			Desert Shield/Desert Storm
			Vietnam War
			Korean War
			World War II
			Peacetime Service
			Other
			Not Applicable
RJB00022		What were you trying to accomplish today in My HealtheVet? (please select all that apply)	Enter/keep track of personal information (My Caregivers, etc.)		Check-boxes	Multi	Y
			Enter/keep track of personal health care information (blood pressure, blood sugar, etc.)
			Look up information about a medication
			Request a prescription refill
			Access prescription history from my VA medical record
			Secure message a provider
			View lab results
			Download my data using the VA Blue Button_x000D_
			Learn about what features are available_x000D_
			View my VA Appointments
			Find a VA health care facility
			Research a health condition
			Find information about VA Benefits
			Other (please specify)	A
RJB00022other	A	Other - trying to accomplish			Text field, <100 char	Single	N
ALM0172		Did you accomplish what you wanted to in My HealtheVet?	Yes		Dropdown (Select-one)	Single	Y
			No
			Partially	A, C
			Not finished yet
RJB00026		Are you a registered user on the MyHealtheVet web site?	Yes		Dropdown (Select-one)	Single	Y
			No
			Not sure
RJB00027		Have you visited your VA Facility in person to show your ID and be "in-person authenticated" (IPA) for My HealtheVet?	Yes		Dropdown (Select-one)	Single	Y
			No
			Not sure
			Not applicable
EDO07291		Did you use a VA medical facility or service for any of your health care needs in the last 12 months?	Yes		Dropdown (Select-one)	Single	Y
			No
RJB00029		My use of the My HealtheVet personal health record has improved my ability to manage my health.	Strongly agree		Drop down, select one	Single	Y
			Agree
			Not sure
			Disagree
			Strongly disagree
			Not applicable
ACQhar0017783		Do you ever access the Internet using a mobile phone or tablet?	Yes	A, B	Radio button, one-up vertical	Single	Y	Access Mobile Internet
			No
ACQhar0017784	A	Which of the following devices do you have?	A SmartPhone	W	Checkbox, one-up vertical	Multi	Y	Phone or Tablet
			A tablet	X
			None of these
ACQhar0017786	W	Specifically, which type of mobile phone do you have?	iPhone		Radio button, one-up vertical	Single	Y	Phone Type
			Android
			Blackberry
			Another phone
ACQhar0017759	X	Specifically, which type of tablet do you have?	iPad		Radio button, one-up vertical	Single	Y	Tablet Type
			Kindle
			Android
			Blackberry
			Another tablet
ACQhar0017785	B	Have you ever accessed ANY federal website using a mobile phone or tablet?	Yes	C	Radio button, one-up vertical	Single	Y	Federal Mobile Site Usage
			No, but I plan to do so
			No, but I might in the future
			No, and I don't plan to do so
ACQhar0017760	C	Have you ever accessed My HealtheVet using a mobile phone or tablet?	Yes	Y, Z	Radio button, one-up vertical	Single	Y	Mobile Site Usage
			No, but I plan to do so	Z
			No, but I might in the future	Z
			No, and I don't plan to do so
ACQhar0017761	Y	What was the main reason you last visited My HealtheVet using a mobile phone or tablet?			Text area, no char limit	Single	N	Mobile Primary Reason
ACQhar0017762	Z	What additional resources might you want to access from My HealtheVet using a mobile phone or tablet?			Text area, no char limit	Single	N	MobileDesired Resources
ALM0173		What is the main improvement that you would suggest for the My HealtheVet web site?			Open-ended	Single	N
ACQLiv0018816		Please rate the clarity of the wording on this site.	1=Poor		Radio button, scale, has don't know	S	Y	Clear
			2
			3
			4
			5
			6
			7
			8
			9
			Excellent=10
			Don't know
ACQLiv0018817		Please rate how well you understand the wording on this site.	1=Poor		Radio button, scale, has don't know	S	Y	Understandable
			2
			3
			4
			5
			6
			7
			8
			9
			Excellent=10
			Don't know
ACQLiv0018818		Please rate the site on its use of short, clear sentences.	1=Poor		Radio button, scale, has don't know	S	Y	Concise
			2
			3
			4
			5
			6
			7
			8
			9
			Excellent=10
			Don't know
AED02714		What is your age range?	Under 20		Dropdown (Select-one)	Single	N
			20-24
			25-29
			30-34
			35-39
			40-44
			45-49
			50-54
			55-59
			60-64
			65-69
			70-74
			75-79
			80-84
			85 or older
JIC00267		What is your gender?	Male		Dropdown (Select-one)	Single	N
			Female
JIC00178		In general, how would you rate your overall health?	Excellent		Dropdown (Select-one)	Single	Y
			Very Good
			Good
			Fair
			Poor
CJI0298		Do you have any of the following health problems? (check all that apply)	Prefer not to answer		Checkbox, one-up vertical	Multi	Y	Health Problems
			Diabetes
			High Blood Pressure
			High Cholesterol
			Heart Disease
			Previous Heart Attack
			Heart Failure
			Lung Disease/Asthma
			Spinal Cord Injury
			Arthritis of any kind
			Cancer
			Mental Health Problems
			Orthopedic Problems
			Ulcer or Stomach Disease
			Pain
			Anemia or other Blood Disease
			None of the above
CJI0299		Please rate your ability in using the Internet:	Beginner or novice (just starting/don't use Internet much)		Radio button, one-up vertical	Single	Y	Internet Ability
			Intermediate (use the Internet for a few things)
			Advanced (frequently use Internet & search for information)
AED06379		Have you completed this survey within the past 3 months?	Yes		Radio button, one-up vertical
			No			Single	N
			Don't recall

---

Sheet 14: Custom Qsts (11-16-12)

Model Instance Name: VA - My HealtheVet				red & strike-through: DELETE
MID:		NJxFtMU9UosBkJZRd48x9Q==		underlined & italicized: RE-ORDER
				pink: ADDITION
Date:		6/23/2009		blue + -->: REWORDING
				violet (bold): SKIP-LOGIC
MID: CUSTOM QUESTION LIST
QID		Skip Logic Label	Question Text	Answer Choices (limited to 50 characters)	Skip to	Type (select from list)	Single or Multi	Required Y/N	Question Label
ALM0169			How frequently do you visit the My HealtheVet web site?	First time		Dropdown (Select-one)	Single	Y
				Daily
				More than once a day
				About once a week
				About once a month
				About every 6 months
				Less than every 6 months
ALM0170			Which of the following best describes you?	Active duty		Checkbox, one-up vertical	Multi	Y
				Veteran
				Family member of a veteran
				Veteran service organization
				News media
				General public
				VA employee
				Federal government employee
				State/local government employee
				Other role
RJB00048			Please indicate your military period(s) of service:	Global War on Terror (OEF/OIF)		Check-boxes	Multi	N
				Desert Shield/Desert Storm
				Vietnam War
				Korean War
				World War II
				Peacetime Service
				Other
				Not Applicable
RJB00022			What were you trying to accomplish today in My HealtheVet? (please select all that apply)	Enter/keep track of personal information (My Caregivers, etc.)		Check-boxes	Multi	Y
				Enter/keep track of personal health care information (blood pressure, blood sugar, etc.)
				Look up information about a medication
				Request a prescription refill
				Access prescription history from my VA medical record
				Secure message a provider
				View lab results
				Download my data using the VA Blue Button_x000D_
				Learn about what features are available_x000D_
				View my VA Appointments
				Find a VA health care facility
				Research a health condition
				Find information about VA Benefits
				Other (please specify)	A
RJB00022other		A	Other - trying to accomplish			Text field, <100 char	Single	N
ALM0172			Did you accomplish what you wanted to in My HealtheVet?	Yes		Dropdown (Select-one)	Single	Y
				No
				Partially	A, C
				Not finished yet
RJB00026			Are you a registered user on the MyHealtheVet web site?	Yes		Dropdown (Select-one)	Single	Y
				No
				Not sure
RJB00027			Have you visited your VA Facility in person to show your ID and be "in-person authenticated" (IPA) for My HealtheVet?	Yes		Dropdown (Select-one)	Single	Y
				No
				Not sure
				Not applicable
EDO07291			Did you use a VA medical facility or service for any of your health care needs in the last 12 months?	Yes		Dropdown (Select-one)	Single	Y
				No
RJB00029			My use of the My HealtheVet personal health record has improved my ability to manage my health.	Strongly agree		Drop down, select one	Single	Y
				Agree
				Not sure
				Disagree
				Strongly disagree
				Not applicable
ACQhar0017783			Do you ever access the Internet using a mobile phone or tablet?	Yes	A, B	Radio button, one-up vertical	Single	Y	Access Mobile Internet
				No
ACQhar0017784		A	Which of the following devices do you have?	A SmartPhone	W	Checkbox, one-up vertical	Multi	Y	Phone or Tablet
				A tablet	X
				None of these
ACQhar0017786		W	Specifically, which type of mobile phone do you have?	iPhone		Radio button, one-up vertical	Single	Y	Phone Type
				Android
				Blackberry
				Another phone
ACQhar0017759		X	Specifically, which type of tablet do you have?	iPad		Radio button, one-up vertical	Single	Y	Tablet Type
				Kindle
				Android
				Blackberry
				Another tablet
ACQhar0017785		B	Have you ever accessed ANY federal website using a mobile phone or tablet?	Yes	C	Radio button, one-up vertical	Single	Y	Federal Mobile Site Usage
				No, but I plan to do so
				No, but I might in the future
				No, and I don't plan to do so
ACQhar0017760		C	Have you ever accessed My HealtheVet using a mobile phone or tablet?	Yes	Y, Z	Radio button, one-up vertical	Single	Y	Mobile Site Usage
				No, but I plan to do so	Z
				No, but I might in the future	Z
				No, and I don't plan to do so
ACQhar0017761		Y	What was the main reason you last visited My HealtheVet using a mobile phone or tablet?			Text area, no char limit	Single	N	Mobile Primary Reason
ACQhar0017762		Z	What additional resources might you want to access from My HealtheVet using a mobile phone or tablet?			Text area, no char limit	Single	N	MobileDesired Resources
ALM0173			What is the main improvement that you would suggest for the My HealtheVet web site?			Open-ended	Single	N
			Please rate the clarity of the wording on this site.	1=Poor		Radio button, scale, has don't know	S	Y	Clear
				2
				3
				4
				5
				6
				7
				8
				9
				Excellent=10
				Don't know
			Please rate how well you understand the wording on this site.	1=Poor		Radio button, scale, has don't know	S	Y	Understandable
				2
				3
				4
				5
				6
				7
				8
				9
				Excellent=10
				Don't know
			Please rate the site on its use of short, clear sentences.	1=Poor		Radio button, scale, has don't know	S	Y	Concise
				2
				3
				4
				5
				6
				7
				8
				9
				Excellent=10
				Don't know
AED02714			What is your age range?	Under 20		Dropdown (Select-one)	Single	N
				20-24
				25-29
				30-34
				35-39
				40-44
				45-49
				50-54
				55-59
				60-64
				65-69
				70-74
				75-79
				80-84
				85 or older
JIC00267			What is your gender?	Male		Dropdown (Select-one)	Single	N
				Female
JIC00178			In general, how would you rate your overall health?	Excellent		Dropdown (Select-one)	Single	Y
				Very Good
				Good
				Fair
				Poor
CJI0298			Do you have any of the following health problems? (check all that apply)	Prefer not to answer		Checkbox, one-up vertical	Multi	Y	Health Problems
				Diabetes
				High Blood Pressure
				High Cholesterol
				Heart Disease
				Previous Heart Attack
				Heart Failure
				Lung Disease/Asthma
				Spinal Cord Injury
				Arthritis of any kind
				Cancer
				Mental Health Problems
				Orthopedic Problems
				Ulcer or Stomach Disease
				Pain
				Anemia or other Blood Disease
				None of the above
CJI0299			Please rate your ability in using the Internet:	Beginner or novice (just starting/don't use Internet much)		Radio button, one-up vertical	Single	Y	Internet Ability
				Intermediate (use the Internet for a few things)
				Advanced (frequently use Internet & search for information)
AED06379			Have you completed this survey within the past 3 months?	Yes		Radio button, one-up vertical
				No			Single	N
				Don't recall

---

Sheet 15: Custom Qsts (11-1-12)

Model Instance Name: VA - My HealtheVet				red & strike-through: DELETE
MID:		NJxFtMU9UosBkJZRd48x9Q==		underlined & italicized: RE-ORDER
				pink: ADDITION
Date:		6/23/2009		blue + -->: REWORDING
				violet (bold): SKIP-LOGIC
MID: CUSTOM QUESTION LIST
QID		Skip Logic Label	Question Text	Answer Choices (limited to 50 characters)	Skip to	Type (select from list)	Single or Multi	Required Y/N	Question Label
ALM0169	1		How frequently do you visit the My HealtheVet web site?	First time		Dropdown (Select-one)	Single	Y
				Daily
				More than once a day
				About once a week
				About once a month
				About every 6 months
				Less than every 6 months
ALM0170	2		Which of the following best describes you?	Active duty		Checkbox, one-up vertical	Multi	Y
				Veteran
				Family member of a veteran
				Veteran service organization
				News media
				General public
				VA employee
				Federal government employee
				State/local government employee
				Other role
RJB00048	3		Please indicate your military period(s) of service:	Global War on Terror (OEF/OIF)		Check-boxes	Multi	N
				Desert Shield/Desert Storm
				Vietnam War
				Korean War
				World War II
				Peacetime Service
				Other
				Not Applicable
RJB00022	4		What were you trying to accomplish today in My HealtheVet? (please select all that apply)	Enter/keep track of personal information (My Caregivers, etc.)		Check-boxes	Multi	Y
				Enter/keep track of personal health care information (blood pressure, blood sugar, etc.)
				Look up information about a medication
				Request a prescription refill
				Access prescription history from my VA medical record
				Secure message a provider
				View lab results
				Download my data using the VA Blue Button_x000D_
				Learn about what features are available_x000D_
				View my VA Appointments
				Find a VA health care facility
				Research a health condition
				Find information about VA Benefits
				Other (please specify)	A
RJB00022other	5	A	Other - trying to accomplish			Text field, <100 char	Single	N
ALM0172	6		Did you accomplish what you wanted to in My HealtheVet?	Yes		Dropdown (Select-one)	Single	Y
				No
				Partially	A, C
				Not finished yet
RJB00026	95		Are you a registered user on the MyHealtheVet web site?	Yes		Dropdown (Select-one)	Single	Y
				No
				Not sure
RJB00027	96		Have you visited your VA Facility in person to show your ID and be "in-person authenticated" (IPA) for My HealtheVet?	Yes		Dropdown (Select-one)	Single	Y
				No
				Not sure
				Not applicable
EDO07291	97		Did you use a VA medical facility or service for any of your health care needs in the last 12 months?	Yes		Dropdown (Select-one)	Single	Y
				No
RJB00029	98		My use of the My HealtheVet personal health record has improved my ability to manage my health.	Strongly agree		Drop down, select one	Single	Y
				Agree
				Not sure
				Disagree
				Strongly disagree
				Not applicable
			Do you ever access the Internet using a mobile phone or tablet?	Yes	A, B	Radio button, one-up vertical	Single	Y	Access Mobile Internet
				No
		A	Which of the following devices do you have?	A SmartPhone	W	Radio button, one-up vertical	Multi	Y	Phone or Tablet
				A tablet	X
				None of these
		W	Specifically, which type of mobile phone do you have?	iPhone		Radio button, one-up vertical	Single	Y	Phone Type
				Android
				Blackberry
				Another phone
		X	Specifically, which type of tablet do you have?	iPad		Radio button, one-up vertical	Single	Y	Tablet Type
				Kindle
				Android
				Blackberry
				Another tablet
		B	Have you ever accessed ANY federal website using a mobile phone or tablet?	Yes	C	Radio button, one-up vertical	Single	Y	Federal Mobile Site Usage
				No, but I plan to do so
				No, but I might in the future
				No, and I don't plan to do so
		C	Have you ever accessed My HealtheVet using a mobile phone or tablet?	Yes	Y, Z	Radio button, one-up vertical	Single	Y	Mobile Site Usage
				No, but I plan to do so	Z
				No, but I might in the future	Z
				No, and I don't plan to do so
		Y	What was the main reason you last visited My HealtheVet using a mobile phone or tablet?			Text area, no char limit	Single	N	Mobile Primary Reason
		Z	What additional resources might you want to access from My HealtheVet using a mobile phone or tablet?			Text area, no char limit	Single	N	MobileDesired Resources
ALM0173	99		What is the main improvement that you would suggest for the My HealtheVet web site?			Open-ended	Single	N
AED02714	100		What is your age range?	Under 20		Dropdown (Select-one)	Single	N
				20-24
				25-29
				30-34
				35-39
				40-44
				45-49
				50-54
				55-59
				60-64
				65-69
				70-74
				75-79
				80-84
				85 or older
JIC00267	101		What is your gender?	Male		Dropdown (Select-one)	Single	N
				Female
JIC00178	102		In general, how would you rate your overall health?	Excellent		Dropdown (Select-one)	Single	Y
				Very Good
				Good
				Fair
				Poor
CJI0298	103		Do you have any of the following health problems? (check all that apply)	Prefer not to answer		Checkbox, one-up vertical	Multi	Y	Health Problems
				Diabetes
				High Blood Pressure
				High Cholesterol
				Heart Disease
				Previous Heart Attack
				Heart Failure
				Lung Disease/Asthma
				Spinal Cord Injury
				Arthritis of any kind
				Cancer
				Mental Health Problems
				Orthopedic Problems
				Ulcer or Stomach Disease
				Pain
				Anemia or other Blood Disease
				None of the above
CJI0299	104		Please rate your ability in using the Internet:	Beginner or novice (just starting/don't use Internet much)		Radio button, one-up vertical	Single	Y	Internet Ability
				Intermediate (use the Internet for a few things)
				Advanced (frequently use Internet & search for information)
AED06379	116		Have you completed this survey within the past 3 months?	Yes		Radio button, one-up vertical
				No			Single	N
				Don't recall

---

Sheet 16: Current Custom Qsts (5-21-12)

Model Instance Name: VA - My HealtheVet					red & strike-through: DELETE
MID:		NJxFtMU9UosBkJZRd48x9Q==			underlined & italicized: RE-ORDER
					pink: ADDITION
Date:		6/23/2009			blue + -->: REWORDING
					violet (bold): SKIP-LOGIC
MID: CUSTOM QUESTION LIST
QID		Skip Logic Label	Question Text	Answer IDs (DOT ONLY)	Answer Choices (limited to 50 characters)	Skip to	Type (select from list)	Single or Multi	Required Y/N	Special Instructions	Question Label
ALM0169	1		How frequently do you visit the My HealtheVet web site?		First time		Dropdown (Select-one)	Single	Y
					Daily
					More than once a day
					About once a week
					About once a month
					About every 6 months
					Less than every 6 months
ALM0170	2		Which of the following best describes you?		Active duty		Checkbox, one-up vertical	Multi	Y
					Veteran
					Family member of a veteran
					Veteran service organization
					News media
					General public
					VA employee
					Federal government employee
					State/local government employee
					Other role
RJB00048	3		Please indicate your military period(s) of service:		Global War on Terror (OEF/OIF)		Check-boxes	Multi	N
					Desert Shield/Desert Storm
					Vietnam War
					Korean War
					World War II
					Peacetime Service
					Other
					Not Applicable
RJB00022	4		What were you trying to accomplish today in My HealtheVet? (please select all that apply)		Enter/keep track of personal information (My Caregivers, etc.)		Check-boxes	Multi	Y
					Enter/keep track of personal health care information (blood pressure, blood sugar, etc.)
					Look up information about a medication
					Request a prescription refill
					Access prescription history from my VA medical record
					Secure message a provider
					View lab results
					Download my data using the VA Blue Button_x000D_
					Learn about what features are available_x000D_
					View my VA Appointments
					Find a VA health care facility
					Research a health condition
					Find information about VA Benefits
					Other (please specify)	A
RJB00022other	5	A	Other - trying to accomplish				Text field, <100 char	Single	N
ALM0172	6		Did you accomplish what you wanted to in My HealtheVet?		Yes		Dropdown (Select-one)	Single	Y
					No
					Partially	A, C
					Not finished yet
CJI0210	7		Have you ever used the “VA Blue Button: Download My Data” feature in My HealtheVet?	CJI0210A001	No	NU-1, NU-2, NU-3, NU-4, NU-5, NU-6A, NU-6B, NU-6C, NU-6D, NU-6E, NU-6F, NU-6G, NU-6H, NU-6I, NU-7	Radio button, one-up vertical	Single	Y	Skip Logic Group	Blue Button Usage
				CJI0210A002	Yes- I used it one or more times but don’t plan to use it again	NR-1, NR-2, NR-3, NR-4, NR-5, NR-6, NR-7A, NR-7B, NR-7C, NR-7D, NR-7E, NR-7F, NR-7G, NR-8
				CJI0210A003	Yes- I have used it just one time, but plan to use it again	CU-1, CU-2, CU-3, CU-4, CU-5, CU-6, CU-7A, CU-7B, CU-7C, CU-7D, CU-7E, CU-7F, CU-8, CU-9
				CJI0210A004	Yes- and I currently use it regularly	CU-1, CU-2, CU-3, CU-4, CU-5, CU-6, CU-7A, CU-7B, CU-7C, CU-7D, CU-7E, CU-7F, CU-8, CU-9
				CJI0210A005	Not Sure
CJI0211	8	NU-1		CJI0211A001	I was not aware of it			Single	Y	Skip Logic Group	NU-1
				CJI0211A002	I am aware of it, but have not used it	NU-1A	Radio button, one-up vertical
CJI0212	9	NU-1A	Why haven't you used the VA Blue Button? (Check ALL that Apply).	CJI0212A001	I do not know where the Blue Button is on the My HealtheVet.website		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	NU-1A
				CJI0212A002	I do not know how to use it
				CJI0212A003	I do not think it would be useful
				CJI0212A004	I only use My HealtheVet to renew my prescriptions.
				CJI0212A005	I prefer to use other methods for keeping track of my health
				CJI0212A006	Other, please specify	NU-1A1
CJI0213	10	NU-1A1	What other reason haven't you used the VA Blue Button?				Text area, no char limit		N	Skip Logic Group	NU-1A1
CJI0214	11	NU-2	We are interested in how veterans keep a record of their health information. On a scale from 1 to 5, how important to you is keeping your own record of your personal health information?	CJI0214A001	1 - Not at all Important		Radio button, one-up vertical	Single	Y	Skip Logic Group	NU-2
				CJI0214A002	2 - A little Important
				CJI0214A003	3 - Somewhat Important
				CJI0214A004	4 - Very Important
				CJI0214A005	5 - Extremely important
CJI0215	12	NU-3	Do you have a system for organizing your health information?	CJI0215A001	No		Radio button, one-up vertical	Single	Y	Skip Logic Group	NU-3
				CJI0215A002	Yes	NU-3A, NU-3B, NU-3C, NU-3D
CJI0216	13	NU-3A	What health information do you keep track of? (Check ALL that apply)	CJI0216A001	My current prescription medications		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	NU-3A
				CJI0216A002	Supplements, vitamins, and over-the-counter medications I am taking.
				CJI0216A003	Medications I have taken in the past
				CJI0216A004	Lab results
				CJI0216A005	Health information such as weight, blood pressure, blood sugar
				CJI0216A006	Major health events such as heart attacks or serious accidents or injuries
				CJI0216A007	Past surgeries
				CJI0216A008	Doctors visits
				CJI0216A009	Hospitalizations
				CJI0216A010	Names and contact information of my health care providers
				CJI0216A011	Other, please specify	NU-3A1
CJI0217	14	NU-3A1	What other health information do you keep track of?				Text area, no char limit		N	Skip Logic Group	NU-3A1
CJI0218	15	NU-3B	Which of the following ways do your store your health information? (Check ALL that you use)	CJI0218A001	Paper files of my health information		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	NU-3A
				CJI0218A002	Files with health care bills and receipts
				CJI0218A003	Computer files of my health information
				CJI0218A004	Web-based electronic personal health records, including My HealtheVet
				CJI0218A005	A calendar where I keep track of appointments and other health information
				CJI0218A006	None of the above- My health care providers maintain all my medical records
				CJI0218A007	Other, please specify	NU-3B1
CJI0219	16	NU-3B1	What other ways do you store information?				Text area, no char limit		N	Skip Logic Group	NU-3A2
CJI0220	17	NU-3C	For what purposes do you keep track of this information? (Check ALL that apply.)	CJI0220A001	For my own use as a reminder of the care I have received		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	NU-3A
				CJI0220A002	To share with doctors
				CJI0220A003	To share with family members or friends who help take care of me
				CJI0220A004	For insurance purposes
				CJI0220A005	To monitor change in my health status over time (i.e. change in blood pressure)
				CJI0220A006	In case of emergency for family and care providers
				CJI0220A007	Other, please specify	NU-3C1
CJI0221	18	NU-3C1	For what other purpose do you track this information?				Text area, no char limit		N	Skip Logic Group	NU-3A3
CJI0222	19	NU-3D	On a scale from 1 to 5, how satisfied are you with your current system of organizing your health information?	CJI0222A001	1 - Not at all Satisfied		Radio button, one-up vertical	Single	Y	Skip Logic Group	NU-3A
				CJI0222A002	2 - A Little Satisfied
				CJI0222A003	3 - Somewhat Satisfied
				CJI0222A004	4 - Very Satisfied
				CJI0222A005	5 - Extremely Satisfied
CJI0223	20	NU-4	Do you see any health care providers who are not affiliated with the VA?	CJI0223A001	No		Radio button, one-up vertical	Single	Y	Skip Logic Group	NU-4
				CJI0223A002	Yes	NU-4A, NU-4B
CJI0224	21	NU-4A	How do your VA providers and non-VA providers communicate about your healthcare?	CJI0224A001	I share information between them		Radio button, one-up vertical	Single	Y	Skip Logic Group	NU-4A
				CJI0224A002	They exchange medical records via mail or fax
				CJI0224A003	They speak by phone
				CJI0224A004	I do not know how they communicate
				CJI0224A005	They do not communicate
				CJI0224A006	Other, please specify	NU-4A1
CJI0225	22	NU-4A1	How else do you communicate?				Text area, no char limit		N	Skip Logic Group	NU-4A1
CJI0226	23	NU-4B	How satisfied are you with the communication about your medications and health care between your VA providers and the providers outside of the VA?	CJI0226A001	1 - Not at all Satisfied		Radio button, one-up vertical	Single	Y	Skip Logic Group	NU-4A
				CJI0226A002	2 - A little Satisfied
				CJI0226A003	3 - Somewhat Satisfied
				CJI0226A004	4 - Very Satisfied
				CJI0226A005	5 - Extremely Satisfied
CJI0227	24	NU-5	We are interested in learning what Veterans would like to help them better manage their health information. Which of the following features would you like to have in your current system for storing your health information? (Check ALL that apply.)	CJI0227A001	The ability to organize the information into specific categories (i.e. medications, doctors visits, hospitalizations, wellness checks, and preventive screens)		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	NU-5
				CJI0227A002	The ability to locate easily information about care I have received in the past
				CJI0227A003	The ability to send summaries of my health information electronically to caregivers, health care providers, or insurance companies
				CJI0227A004	The ability to store all my health information on a small portable disk or device so I can have it with me at all times
				CJI0227A005	Other, please specify	NU-5A
CJI0228	25	NU-5A	What other feature are you interested in?				Text area, no char limit		N	Skip Logic Group	NU-5A
CJI0229	26	NU-6A	We are interested in helping Veterans to use the Blue Button Feature of My HealtheVet. Please read the items below and indicate whether or not it would make it more likely that you would use the Blue Button. Would you be more likely to use the Blue Button if . . Your doctor, nurse, or other care provider strongly recommended you use the Blue Button?	CJI0229A001	I would still not use the Blue Button if this happened		Radio button, one-up vertical	Single	Y	Skip Logic Group	NU-6
				CJI0229A002	I might use the Blue Button if this happened
				CJI0229A003	I would definitely use the Blue Button if this happened.
CJI0230	27	NU-6B	Another veteran strongly recommended you use the Blue Button?	CJI0230A001	I would still not use the Blue Button if this happened		Radio button, one-up vertical	Single	Y	Skip Logic Group	NU-6
				CJI0230A002	I might use the Blue Button if this happened
				CJI0230A003	I would definitely use the Blue Button if this happened.
CJI0231	28	NU-6C	Using it would remind you of when your VA appointments are?	CJI0231A001	I would still not use the Blue Button if this happened		Radio button, one-up vertical	Single	Y	Skip Logic Group	NU-6
				CJI0231A002	I might use the Blue Button if this happened
				CJI0231A003	I would definitely use the Blue Button if this happened.
CJI0232	29	NU-6D	Using it would make it easier for you to give others, such as health care providers or family members, important medical information?	CJI0232A001	I would still not use the Blue Button if this happened		Radio button, one-up vertical	Single	Y	Skip Logic Group	NU-6
				CJI0232A002	I might use the Blue Button if this happened
				CJI0232A003	I would definitely use the Blue Button if this happened.
CJI0233	30	NU-6E	Using it would help you understand better which medications you need to be taking?	CJI0233A001	I would still not use the Blue Button if this happened		Radio button, one-up vertical	Single	Y	Skip Logic Group	NU-6
				CJI0233A002	I might use the Blue Button if this happened
				CJI0233A003	I would definitely use the Blue Button if this happened.
CJI0234	31	NU-6F	Using it would make it easier for you to monitor lab results?	CJI0234A001	I would still not use the Blue Button if this happened		Radio button, one-up vertical	Single	Y	Skip Logic Group	NU-6
				CJI0234A002	I might use the Blue Button if this happened
				CJI0234A003	I would definitely use the Blue Button if this happened.
CJI0235	32	NU-6G	Using it would help you better manage your health in general?	CJI0235A001	I would still not use the Blue Button if this happened		Radio button, one-up vertical	Single	Y	Skip Logic Group	NU-6
				CJI0235A002	I might use the Blue Button if this happened
				CJI0235A003	I would definitely use the Blue Button if this happened.
CJI0236	33	NU-6H	Would you be more likely to use the VA Blue Button if...A VA staff member showed you how to use it?	CJI0236A001	I would still not use the Blue Button if this happened		Radio button, one-up vertical	Single	Y	Skip Logic Group	NU-6
				CJI0236A002	I might use the Blue Button if this happened
				CJI0236A003	I would definitely use the Blue Button if this happened.
CJI0237	34	NU-6I	There was an easy-to-follow booklet showing you how to use it?	CJI0237A001	I would still not use the Blue Button if this happened		Radio button, one-up vertical	Single	Y	Skip Logic Group	NU-6
				CJI0237A002	I might use the Blue Button if this happened
				CJI0237A003	I would definitely use the Blue Button if this happened.
CJI0238	35	NU-7	Please indicate below whether or not you intend to use the Blue Button feature in the future.	CJI0238A001	I will not use the Blue Button in the future.		Radio button, one-up vertical	Single	Y	Skip Logic Group	NU-7
				CJI0238A002	I might use the Blue Button in the future.
				CJI0238A003	I will definitely use the Blue Button in the future.
CJI0239	36	NR-1	We are interested in learning about Veterans who have used the Blue Button, but do not plan to use it again. Why do you no longer use the Blue Button Feature of My HealtheVet? (Check ALL that apply)	CJI0239A001	I did not know how to use it		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	NR-1
				CJI0239A002	I could not find what I was looking for	NR-1A
				CJI0239A003	The information in the file/print out was not useful	NR-1A
				CJI0239A004	The file/print out was too long
				CJI0239A005	I would rather use another way to store my health information
				CJI0239A006	Other, please specify	NR-1A1
CJI0240	37	NR-1A1	What other reason do you no longer use the Blue Button?				Text area, no char limit		N	Skip Logic Group	NR-1A1
CJI0241	38	NR-1A	What information did you want to find on the Blue Button file? (Check ALL that apply.)	CJI0241A001	My entire medical record		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	NR-1A
				CJI0241A002	My health record from my military service
				CJI0241A003	My lab results
				CJI0241A004	My appointments
				CJI0241A005	Other, please specify	NR-1A2
CJI0242	39	NR-1A2	What other information did you want to find?				Text area, no char limit		N	Skip Logic Group	NR-1A2
CJI0243	40	NR2	In the past year, My HealtheVet has expanded to include lab results, and appointments. Had you heard about these new features of the Blue Button?	CJI0243A001	No	NR-2A	Radio button, one-up vertical	Single	Y	Skip Logic Group	NR2
				CJI0243A002	Yes
CJI0244	41	NR-2A	Would the ability to view labs and appointments make you more likely to use the Blue Button?	CJI0244A001	No		Radio button, one-up vertical	Single	Y	Skip Logic Group	NR-2A
				CJI0244A002	Yes
CJI0245	42	NR-3	We are interested in how veterans keep a record of their health information. On a scale from 1 to 5, how important to you is keeping your own record of your personal health information?	CJI0245A001	1 - Not at all Important		Radio button, one-up vertical	Single	Y	Skip Logic Group	NR-3
				CJI0245A002	2 - A little Important
				CJI0245A003	3 - Somewhat Important
				CJI0245A004	4 - Very Important
				CJI0245A005	5 - Extremely important
CJI0246	43	NR-4	Do you have a system for organizing your health information?	CJI0246A001	No		Radio button, one-up vertical	Single	Y	Skip Logic Group	NR-4
				CJI0246A002	Yes	NR-4A, NR-4B, NR -4C, NR-4D
CJI0247	44	NR-4A	What health information do you keep track of? (Check ALL that apply)	CJI0247A001	My current prescription medications		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	NR-4A
				CJI0247A002	Supplements, vitamins, and over-the-counter medications I am taking.
				CJI0247A003	Medications I have taken in the past
				CJI0247A004	Lab results
				CJI0247A005	Health information such as weight, blood pressure, blood sugar
				CJI0247A006	Major health events such as heart attacks or serious accidents or injuries
				CJI0247A007	Past surgeries
				CJI0247A008	Doctors visits
				CJI0247A009	Hospitalizations
				CJI0247A010	Names and contact information of my health care providers
				CJI0247A011	Other, please specify	NR-4A1
CJI0248	45	NR-4A1	What other information do you keep track of?				Text area, no char limit		N	Skip Logic Group	NR-4A1
CJI0249	46	NR-4B	Which of the following ways do your store your health information? (Check ALL that you use)	CJI0249A001	Paper files of my health information		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	NR-4A
				CJI0249A002	Files with health care bills and receipts
				CJI0249A003	Computer files of my health information
				CJI0249A004	Web-based electronic personal health records, including My HealtheVet
				CJI0249A005	A calendar where I keep track of appointments and other health information
				CJI0249A006	None of the above- My health care providers maintain all my medical records
				CJI0249A007	Other, please specify	NR-4A2
CJI0250	47	NR-4A2	What other ways do you store your information?				Text area, no char limit		N	Skip Logic Group	NR-4A2
CJI0251	48	NR-4C	For what purposes do you keep track of this information?(Check ALL that apply.)	CJI0251A001	For my own use as a reminder of the care I have received		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	NR-4A
				CJI0251A002	To share with doctors
				CJI0251A003	To share with family members or friends who help take care of me
				CJI0251A004	For insurance purposes
				CJI0251A005	To monitor change in my health status over time (i.e. change in blood pressure)
				CJI0251A006	In case of emergency for family and care providers
				CJI0251A007	Other, please specify	NR-4A3
CJI0252	49	NR-4A3	For what other purposes do you track this information?				Text area, no char limit		N	Skip Logic Group	NR-4A3
CJI0253	50	NR-4D	On a scale from 1 to 5, how satisfied are you with your current system of organizing your health information?	CJI0253A001	1 - Not at all Satisfied		Radio button, one-up vertical	Single	Y	Skip Logic Group	NR-4A
				CJI0253A002	2 - A Little Satisfied
				CJI0253A003	3 - Somewhat Satisfied
				CJI0253A004	4 - Very Satisfied
				CJI0253A005	5 - Extremely Satisfied
CJI0254	51	NR-5	Do you see any health care providers who are not affiliated with the VA?	CJI0254A001	No		Radio button, one-up vertical	Single	Y	Skip Logic Group	NR-5
				CJI0254A002	Yes	NR-5A, NR-5B
CJI0255	52	NR-5A	How do your VA providers and non-VA providers communicate about your healthcare?	CJI0255A001	I share information between them		Radio button, one-up vertical	Single	Y	Skip Logic Group	NR-5A
				CJI0255A002	They exchange medical records via mail or fax
				CJI0255A003	They speak by phone
				CJI0255A004	I do not know how they communicate
				CJI0255A005	They do not communicate
				CJI0255A006	Other: Please Describe	NR-5A1
CJI0256	53	NR-5A1	Other communication method				Text area, no char limit		N	Skip Logic Group	NR-5A1
CJI0257	54	NR-5B	How satisfied are you with the communication about your medications and health care between your VA providers and the providers outside of the VA?	CJI0257A001	1 - Not at all Satisfied		Radio button, one-up vertical	Single	Y		NR-5A
				CJI0257A002	2 - A little Satisfied
				CJI0257A003	3 - Somewhat Satisfied
				CJI0257A004	4 - Very Satisfied
				CJI0257A005	5 - Extremely Satisfied
CJI0258	55	NR-6	We are interested in learning what Veterans would like to help them better manage their health information. Which of the following features would you like to have in your current system for storing your health information? (Check ALL that apply.)	CJI0258A001	The ability to organize the information into specific categories (i.e. medications, doctors visits, hospitalizations, wellness checks, and preventive screens)		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	NR-6
				CJI0258A002	The ability to locate easily information about care I have received in the past
				CJI0258A003	The ability to send summaries of my health information electronically to caregivers, health care providers, or insurance companies
				CJI0258A004	The ability to store all my health information on a small portable disk or device so I can have it with me at all times
				CJI0258A005	Other, please specify	NR-6A
CJI0259	56	NR-6A	What other feature would you like to have?				Text area, no char limit		N	Skip Logic Group	NR-6A
CJI0260	57	NR-7A	We are interested in helping Veterans to use the Blue Button Feature of My HealtheVet. Please read the items below and indicate whether or not it would make it more likely that you would use the Blue Button. Would you be more likely to use the Blue Button if . . Your doctor, nurse, or other care provider strongly recommended you use the Blue Button?	CJI0260A001	I would still not use the Blue Button if this happened		Radio button, one-up vertical	Single	Y		NR-7
				CJI0260A002	I might use the Blue Button if this happened
				CJI0260A003	I would definitely use the Blue Button if this happened.
CJI0261	58	NR-7B	Another veteran strongly recommended you use the Blue Button?	CJI0261A001	I would still not use the Blue Button if this happened		Radio button, one-up vertical	Single	Y	Skip Logic Group	NR-7
				CJI0261A002	I might use the Blue Button if this happened
				CJI0261A003	I would definitely use the Blue Button if this happened.
CJI0262	59	NR-7C	Using it would remind you of when your VA appointments are?	CJI0262A001	I would still not use the Blue Button if this happened		Radio button, one-up vertical	Single	Y	Skip Logic Group	NR-7
				CJI0262A002	I might use the Blue Button if this happened
				CJI0262A003	I would definitely use the Blue Button if this happened.
CJI0263	60	NR-7D	Using it would make it easier for you to give others, such as health care providers or family members, important medical information?	CJI0263A001	I would still not use the Blue Button if this happened		Radio button, one-up vertical	Single	Y	Skip Logic Group	NR-7
				CJI0263A002	I might use the Blue Button if this happened
				CJI0263A003	I would definitely use the Blue Button if this happened.
CJI0264	61	NR-7E	Using it would help you understand better which medications you need to be taking?	CJI0264A001	I would still not use the Blue Button if this happened		Radio button, one-up vertical	Single	Y	Skip Logic Group	NR-7
				CJI0264A002	I might use the Blue Button if this happened
				CJI0264A003	I would definitely use the Blue Button if this happened.
CJI0265	62	NR-7F	Using it would make it easier for you to monitor lab results?	CJI0265A001	I would still not use the Blue Button if this happened		Radio button, one-up vertical	Single	Y	Skip Logic Group	NR-7
				CJI0265A002	I might use the Blue Button if this happened
				CJI0265A003	I would definitely use the Blue Button if this happened.
CJI0266	63	NR-7G	Using it would help you better manage your health in general?	CJI0266A001	I would still not use the Blue Button if this happened		Radio button, one-up vertical	Single	Y	Skip Logic Group	NR-7
				CJI0266A002	I might use the Blue Button if this happened
				CJI0266A003	I would definitely use the Blue Button if this happened.
CJI0267	64	NR-8	Please indicate below whether or not you intend to use the Blue Button feature in the future.	CJI0267A001	I will not use the Blue Button in the future.		Radio button, one-up vertical	Single	Y	Skip Logic Group	NU-8
				CJI0267A002	I might use the Blue Button in the future.
				CJI0267A003	I will definitely use the Blue Button in the future.
CJI0268	65	CU-1	We are interested in learning about how Veterans are using the Blue Button. How did you typically use the VA Blue Button? (Check ALL that apply)	CJI0268A001	I use it to view my health information on the My HealtheVet website		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	CU-1
				CJI0268A002	I use it to create an electronic file of my health information (for example, saved a file to your computer)
				CJI0268A003	I print a paper copy of my health information
CJI0269	66	CU-2	What information were you interested in when getting your health information through the Blue Button? ( Check ALL that apply)	CJI0269A001	My current VA medication list		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	CU-2
				CJI0269A002	My entire VA medication history (all medications prescribed for me while I have been a patient at the VA)
				CJI0269A003	My lab results
				CJI0269A004	My list of medications prescribed outside of the VA (self-entered in My HealtheVet)
				CJI0269A005	My list of over-the-counter, supplement, or herbal medications (self-entered in MyHealtheVet)
				CJI0269A006	A list of my providers and their contact information (self-entered into My HealtheVet)
				CJI0269A007	Other, please specify	CU-2A
CJI0270	67	CU-2A	What other information were you interested in?				Text area, no char limit		N	Skip Logic Group	CU-2A
CJI0271	68	CU-3	What did you do with your Blue Button print out or file? (Check ALL that apply)	CJI0271A001	I saved it for my records		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	CU-3
				CJI0271A002	I read it
				CJI0271A003	I shared it (or plan to share it) with my VA health care provider	CU-3A, CU-3B, CU-3C
				CJI0271A004	I shared it (or plan to share it) with my spouse, child, or other family member
				CJI0271A005	I shared it (or plan to share it) with my non-VA health care provider	CU-3A, CU-3B, CU-3C
				CJI0271A006	I did not keep the information (for example, deleted the file or threw away the print copy)
				CJI0271A007	Other, please specify	CU-3A1
CJI0272	69	CU-3A1	What else did you do with your Blue Button print out or file?				Text area, no char limit		N	Skip Logic Group	CU-3A1
CJI0273	70	CU-3A	What information on the Blue Button print out did you want to show your care provider? (Check ALL that apply)	CJI0273A001	My current V A medication list		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	CU-3A
				CJI0273A002	My entire VA medication history
				CJI0273A003	My lab results
				CJI0273A004	My list of medications prescribed outside of the VA (self-entered in My HealtheVet)
				CJI0273A005	My list of over-the-counter, supplement, or herbal medications (self-entered in MyHealtheVet)
				CJI0273A006	Other, please specify	CU-3A2
CJI0274	71	CU-3A2	What other information did you want to show your provider?				Text area, no char limit		N	Skip Logic Group	CU-3A2
CJI0275	72	CU-3B	What did your provider do with the Blue Button print out? Check ALL that apply.	CJI0275A001	He or she used it to review my complete medication list		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	CU-3A
				CJI0275A002	He or she used it to review recent lab results
				CJI0275A003	He or she used it to find other health information
				CJI0275A004	He or she filed it in my medical record
				CJI0275A005	He or she did not look at it
				CJI0275A006	Other, please specify	CU-3A3
CJI0276	73	CU-3A3	What else did your provider do with the printout?				Text area, no char limit		N	Skip Logic Group	CU-3A3
CJI0277	74	CU-3C	How helpful do you think your care provider found the Blue Button information in making decisions about your care?	CJI0277A001	Not at All Helpful		Radio button, one-up vertical	Single	Y	Skip Logic Group	CU-3A
				CJI0277A002	Somewhat Helpful
				CJI0277A003	Very helpful
				CJI0277A004	Don’t Know
CJI0278	75	CU-4	We are interested in how veterans keep a record of their health information. On a scale from 1 to 5, how important to you is keeping your own record of your personal health information?	CJI0278A001	1 - Not at all Important		Radio button, one-up vertical	Single	Y	Skip Logic Group	CU-4
				CJI0278A002	2 - A little Important
				CJI0278A003	3 - Somewhat Important
				CJI0278A004	4 - Very Important
				CJI0278A005	5 - Extremely important
CJI0279	76	CU-5	Do you have a system for organizing your health information?	CJI0279A001	No		Radio button, one-up vertical	Single	Y	Skip Logic Group	CU-5
				CJI0279A002	Yes	CU-5A, CU-5B
CJI0280	77	CU-5A	What health information do you keep track of? (Check ALL that apply)	CJI0280A001	My current prescription medications		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	CU-5A
				CJI0280A002	Supplements, vitamins, and over-the-counter medications I am taking.
				CJI0280A003	Medications I have taken in the past
				CJI0280A004	Lab results
				CJI0280A005	Health information such as weight, blood pressure, blood sugar
				CJI0280A006	Major health events such as heart attacks or serious accidents or injuries
				CJI0280A007	Past surgeries
				CJI0280A008	Doctors visits
				CJI0280A009	Hospitalizations
				CJI0280A010	Names and contact information of my health care providers
				CJI0280A011	Other, please specify	CU-5A1
CJI0281	78	CU-5A1	What other health information do you keep track of?				Text area, no char limit		N	Skip Logic Group	CU-5A1
CJI0282	79	CU-5B	Which of the following ways do your store your health information? (Check ALL that you use)	CJI0282A001	Paper files of my health information		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	CU-5A
				CJI0282A002	Files with health care bills and receipts
				CJI0282A003	Computer files of my health information
				CJI0282A004	Web-based electronic personal health records, including My HealtheVet
				CJI0282A005	A calendar where I keep track of appointments and other health information
				CJI0282A006	None of the above- My health care providers maintain all my medical records
				CJI0282A007	Other, please specify	CU-5B1
CJI0283	80	CU-5B1	What other was do you store your health information?				Text area, no char limit		N	Skip Logic Group	CU-5A2
CJI0284	81	CU-6	Do you see any health care providers who are not affiliated with the VA?	CJI0284A001	No		Radio button, one-up vertical	Single	Y		CU-6
				CJI0284A002	Yes	CU-6A, CU-6B, CU-6C
CJI0285	82	CU-6A	How do your VA providers and non-VA providers communicate about your healthcare?	CJI0285A001	I share information between them		Radio button, one-up vertical	Single	Y	Skip Logic Group	CU-6A
				CJI0285A002	They exchange medical records via mail or fax
				CJI0285A003	They speak by phone
				CJI0285A004	I do not know how they communicate
				CJI0285A005	They do not communicate
				CJI0285A006	Other, please specify	CU-6A1
CJI0286	83	CU-6A1	How else do your providers communicated about your healthcare?				Text area, no char limit		N	Skip Logic Group	CU-6A1
CJI0287	84	CU-6B	How satisfied are you with the communication about your medications and health care between your VA providers and the providers outside of the VA?	CJI0287A001	1 - Not at all Satisfied		Radio button, one-up vertical	Single	Y	Skip Logic Group	CU-6A
				CJI0287A002	2 - A little Satisfied
				CJI0287A003	3 - Somewhat Satisfied
				CJI0287A004	4 - Very Satisfied
				CJI0287A005	5 - Completely Satisfied
CJI0288	85	CU-6C	Have you ever shared the Blue Button print out with your non-VA providers?	CJI0288A001	No		Radio button, one-up vertical	Single	Y	Skip Logic Group	CU-6A
				CJI0288A002	Yes	CU-6D
CJI0289	86	CU-6D	How helpful do you think your non-VA care provider found the Blue Button information in making decisions about your care?	CJI0289A001	Not at All Helpful		Radio button, one-up vertical	Single	Y	Skip Logic Group	CU-6A
				CJI0289A002	Somewhat Helpful
				CJI0289A003	Very helpful
				CJI0289A004	Don’t Know
CJI0290	87	CU-7A	Please indicate whether or not you agree with the following statements using a scale from 1 (Completely Disagree) to 5 (Completely Agree). The Blue Button feature helps me remember when my VA appointments are.	CJI0290A001	1 - Completely Disagree		Radio button, one-up vertical	Single	Y	Skip Logic Group	CU-7
				CJI0290A002	2 - Somewhat Disagree
				CJI0290A003	3 - Neither Agree nor Disagree
				CJI0290A004	4 - Somewhat Agree
				CJI0290A005	5 - Completely Agree
CJI0291	88	CU-7B	The Blue Button feature helps me understand my health history better because all the information is in one place.	CJI0291A001	1 - Completely Disagree		Radio button, one-up vertical	Single	Y	Skip Logic Group	CU-7
				CJI0291A002	2 - Somewhat Disagree
				CJI0291A003	3 - Neither Agree nor Disagree
				CJI0291A004	4 - Somewhat Agree
				CJI0291A005	5 - Completely Agree
CJI0292	89	CU-7C	The Blue Button feature makes it easier for me to give others, such as health care providers or family members, important medical information?	CJI0292A001	1 - Completely Disagree		Radio button, one-up vertical	Single	Y	Skip Logic Group	CU-7
				CJI0292A002	2 - Somewhat Disagree
				CJI0292A003	3 - Neither Agree nor Disagree
				CJI0292A004	4 - Somewhat Agree
				CJI0292A005	5 - Completely Agree
CJI0293	90	CU-7D	The Blue Button feature helps me understand better which medications I need to be taking.	CJI0293A001	1 - Completely Disagree		Radio button, one-up vertical	Single	Y	Skip Logic Group	CU-7
				CJI0293A002	2 - Somewhat Disagree
				CJI0293A003	3 - Neither Agree nor Disagree
				CJI0293A004	4 - Somewhat Agree
				CJI0293A005	5 - Completely Agree
CJI0294	91	CU-7E	The Blue Button feature makes it easier to monitor lab results.	CJI0294A001	1 - Completely Disagree		Radio button, one-up vertical	Single	Y	Skip Logic Group	CU-7
				CJI0294A002	2 - Somewhat Disagree
				CJI0294A003	3 - Neither Agree nor Disagree
				CJI0294A004	4 - Somewhat Agree
				CJI0294A005	5 - Completely Agree
CJI0295	92	CU-7F	The Blue Button feature has helped me better manage my health in general.	CJI0295A001	1 - Completely Disagree		Radio button, one-up vertical	Single	Y	Skip Logic Group	CU-7
				CJI0295A002	2 - Somewhat Disagree
				CJI0295A003	3 - Neither Agree nor Disagree
				CJI0295A004	4 - Somewhat Agree
				CJI0295A005	5 - Completely Agree
CJI0296	93	CU-8	On a scale from 1 to 10 with 1 being “Not at All Satisfied” and 10 being “Extremely Satisfied”, please rate your overall satisfaction with the Blue Button Feature of My HealtheVet?	CJI0296A001	1 - Not at all Satisfied		Radion button, scale, no don't know	Single	Y	Skip Logic Group	CU-8
				CJI0296A002	2
				CJI0296A003	3
				CJI0296A004	4
				CJI0296A005	5
				CJI0296A006	6
				CJI0296A007	7
				CJI0296A008	8
				CJI0296A009	9
				CJI0296A010	10 - Extremely Satisfied
CJI0297	94	CU-9	Please indicate below whether or not you intend to use the Blue Button feature in the future.	CJI0297A001	I will not use the Blue Button in the future.		Drop down, select one	Single	Y	Skip Logic Group	CU-9
				CJI0297A002	I might use the Blue Button in the future.
				CJI0297A003	I will definitely use the Blue Button in the future.
RJB00026	95		Are you a registered user on the MyHealtheVet web site?		Yes		Dropdown (Select-one)	Single	Y
					No
					Not sure
RJB00027	96		Have you visited your VA Facility in person to show your ID and be "in-person authenticated" (IPA) for My HealtheVet?		Yes		Dropdown (Select-one)	Single	Y
					No
					Not sure
					Not applicable
EDO07291	97		Did you use a VA medical facility or service for any of your health care needs in the last 12 months?	EDO07291A001	Yes		Dropdown (Select-one)	Single	Y
				EDO07291A002	No
RJB00029	98		My use of the My HealtheVet personal health record has improved my ability to manage my health.		Strongly agree		Drop down, select one	Single	Y
					Agree
					Not sure
					Disagree
					Strongly disagree
					Not applicable
ALM0173	99		What is the main improvement that you would suggest for the My HealtheVet web site?				Open-ended	Single	N
AED02714	100		What is your age range?		Under 20		Dropdown (Select-one)	Single	N
					20-24
					25-29
					30-34
					35-39
					40-44
					45-49
					50-54
					55-59
					60-64
					65-69
					70-74
					75-79
					80-84
					85 or older
JIC00267	101		What is your gender?		Male		Dropdown (Select-one)	Single	N
					Female
JIC00178	102		In general, how would you rate your overall health?		Excellent		Dropdown (Select-one)	Single	Y
					Very Good
					Good
					Fair
					Poor
CJI0298	103		Do you have any of the following health problems? (check all that apply)	CJI0298A001	Prefer not to answer		Checkbox, one-up vertical	Multi	Y		Health Problems
				CJI0298A002	Diabetes
				CJI0298A003	High Blood Pressure
				CJI0298A004	High Cholesterol
				CJI0298A005	Heart Disease
				CJI0298A006	Previous Heart Attack
				CJI0298A007	Heart Failure
				CJI0298A008	Lung Disease/Asthma
				CJI0298A009	Spinal Cord Injury
				CJI0298A010	Arthritis of any kind
				CJI0298A011	Cancer
				CJI0298A012	Mental Health Problems
				CJI0298A013	Orthopedic Problems
				CJI0298A014	Ulcer or Stomach Disease
				CJI0298A015	Pain
				CJI0298A016	Anemia or other Blood Disease
				CJI0298A017	None of the above
CJI0299	104		Please rate your ability in using the Internet:	CJI0299A001	Beginner or novice (just starting/don't use Internet much)		Radio button, one-up vertical	Single	Y		Internet Ability
				CJI0299A002	Intermediate (use the Internet for a few things)
				CJI0299A003	Advanced (frequently use Internet & search for information)
CJI0300	105		Which of the following social media sites or tools have you used in the last 2 months? (Check all that apply)	CJI0300A001	VA Sponsored Facebook page	AA	Checkbox, one-up vertical	Multi	Y	Skip Logic Group	Social Media Usage
				CJI0300A002	VA sponsored Twitter accounts	BB
				CJI0300A003	VA Sponsored Blogs	CC
				CJI0300A004	VA Sponsored YouTube Channel	DD
				CJI0300A005	Facebook	EE
				CJI0300A006	Twitter	FF
				CJI0300A007	My Space	GG
				CJI0300A008	YouTube	II
				CJI0300A009	Blogs	HH
				CJI0300A010	Other, please specify:	A
				CJI0300A011	None		exclusive
CJI0301	106	A	What other social media tools have you used?				Text area, no char limit		N
CJI0302	107	AA	Did the VA Sponsored Facebook page provide you with information that made you want to visit and use My HealtheVet?	CJI0302A001	Yes		Radio button, one-up vertical	Single	Y		MHV Use - VA Facebook
				CJI0302A002	No
CJI0303	108	BB	Did the VA sponsored Twitter accounts provide you with information that made you want to visit and use My HealtheVet?	CJI0303A001	Yes		Radio button, one-up vertical	Single	Y		MHV Use - VA Twitter
				CJI0303A002	No
CJI0304	109	CC	Did the VA Sponsored Blogs provide you with information that made you want to visit and use My HealtheVet?	CJI0304A001	Yes		Radio button, one-up vertical	Single	Y		MHV Use - VA Blog
				CJI0304A002	No
CJI0305	110	DD	Did the VA Sponsored YouTube Channel provide you with information that made you want to visit and use My HealtheVet?	CJI0305A001	Yes		Radio button, one-up vertical	Single	Y		MHV Use - VA YouTube
				CJI0305A002	No
CJI0306	111	EE	Did Facebook provide you with information that made you want to visit and use My HealtheVet?	CJI0306A001	Yes		Radio button, one-up vertical	Single	Y		MHV Use - Facebook
				CJI0306A002	No
CJI0307	112	FF	Did Twitter provide you with information that made you want to visit and use My HealtheVet?	CJI0307A001	Yes		Radio button, one-up vertical	Single	Y		MHV Use - Twitter
				CJI0307A002	No
CJI0308	113	GG	Did MySpace provide you with information that made you want to visit and use My HealtheVet?	CJI0308A001	Yes		Radio button, one-up vertical	Single	Y		MHV Use - MySpace
				CJI0308A002	No
CJI0310	114	HH	Did YouTube provide you with information that made you want to visit and use My HealtheVet?	CJI0310A001	Yes		Radio button, one-up vertical	Single	Y		MHV Use - YouTube
				CJI0310A002	No
CJI0309	115	II	Did the Blogs provide you with information that made you want to visit and use My HealtheVet?	CJI0309A001	Yes		Radio button, one-up vertical	Single	Y		MHV Use - Blogs
				CJI0309A002	No
AED06379	116		Have you completed this survey within the past 3 months?		Yes		Radio button, one-up vertical
					No			Single	N
					Don't recall

---

Sheet 17: Custom Qsts (3-8-12)

Model Instance Name: VA - My HealtheVet				red & strike-through: DELETE
MID:	NJxFtMU9UosBkJZRd48x9Q==			underlined & italicized: RE-ORDER
				pink: ADDITION
Date:	6/23/2009			blue + -->: REWORDING
				violet (bold): SKIP-LOGIC
MID: CUSTOM QUESTION LIST
QID	Skip Logic Label	Question Text	Answer IDs (DOT ONLY)	Answer Choices (limited to 50 characters)	Skip to	Type (select from list)	Single or Multi	Required Y/N	Special Instructions	Question Label
ALM0169		How frequently do you visit the My HealtheVet web site?		First time		Dropdown (Select-one)	Single	Y
				Daily
				More than once a day
				About once a week
				About once a month
				About every 6 months
				Less than every 6 months
ALM0170		Which of the following best describes you?		Active duty		Checkbox, one-up vertical	Multi	Y
				Veteran
				Family member of a veteran
				Veteran service organization
				News media
				General public
				VA employee
				Federal government employee
				State/local government employee
				Other role
RJB00048		Please indicate your military period(s) of service:		Global War on Terror (OEF/OIF)		Check-boxes	Multi	N
				Desert Shield/Desert Storm
				Vietnam War
				Korean War
				World War II
				Peacetime Service
				Other
				Not Applicable
RJB00022		What were you trying to accomplish today in My HealtheVet? (please select all that apply)		Enter/keep track of personal information (My Caregivers, etc.)		Check-boxes	Multi	Y
				Enter/keep track of personal health care information (blood pressure, blood sugar, etc.)
				Look up information about a medication
				Request a prescription refill
				Access prescription history from my VA medical record
				Secure message a provider
				View lab results
				Download my data using the VA Blue Button_x000D_
				Learn about what features are available_x000D_
				View my VA Appointments
				Find a VA health care facility
				Research a health condition
				Find information about VA Benefits
				Other (please specify)	A
RJB00022other	A	Other - trying to accomplish				Text field, <100 char	Single	N
ALM0172		Did you accomplish what you wanted to in My HealtheVet?		Yes		Dropdown (Select-one)	Single	Y
				No
				Partially	A, C
				Not finished yet
		Have you ever used the “VA Blue Button: Download My Data” feature in My HealtheVet?		No	NU-1, NU-2, NU-3, NU-4, NU-5, NU-6A, NU-6B, NU-6C, NU-6D, NU-6E, NU-6F, NU-6G, NU-6H, NU-6I, NU-7	Radio button, one-up vertical	Single	Y	Skip Logic Group	Blue Button Usage
				Yes- I used it one or more times but don’t plan to use it again	NR-1, NR-2, NR-3, NR-4, NR-5, NR-7A, NR-7B, NR-7C, NR-7D, NR-7E, NR-7F, NR-7G
				Yes- I have used it just one time, but plan to use it again	CU-1, CU-2, CU-3, CU-4, CU-5, CU-6, CU-7A, CU-7B, CU-7C, CU-7D, CU-7E, CU-7F, CU-8, CU-9
				Yes- and I currently use it regularly	CU-1, CU-2, CU-3, CU-4, CU-5, CU-6, CU-7A, CU-7B, CU-7C, CU-7D, CU-7E, CU-7F, CU-8, CU-9
				Not Sure
	NU-1	Why have you not used the VA Blue Button?		I was not aware of it			Single	Y	Skip Logic Group	NU-1
				I am aware of it, but have not used it	NU-1A	Radio button, one-up vertical
	NU-1A	Why haven't you used the VA Blue Button? (Check ALL that Apply).		I do not know where the Blue Button is on the My HealtheVet.website		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	NU-1A
				I do not know how to use it
				I do not think it would be useful
				I only use My HealtheVet to renew my prescriptions.
				I prefer to use other methods for keeping track of my health
				Other, please specify	NU-1A1
	NU-1A1	What other reason haven't you used the VA Blue Button?				Text area, no char limit		N	Skip Logic Group	NU-1A1
	NU-2	We are interested in how veterans keep a record of their health information. On a scale from 1 to 5, how important to you is keeping your own record of your personal health information?		1 - Not at all Important		Radio button, one-up vertical	Single	Y	Skip Logic Group	NU-2
				2 - A little Important
				3 - Somewhat Important
				4 - Very Important
				5 - Extremely important
	NU-3	Do you have a system for organizing your health information?		No		Radio button, one-up vertical	Single	Y	Skip Logic Group	NU-3
				Yes	NU-3A, NU-3B, NU-3C, NU-3D
	NU-3A	What health information do you keep track of? (Check ALL that apply)		My current prescription medications		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	NU-3A
				Supplements, vitamins, and over-the-counter medications I am taking.
				Medications I have taken in the past
				Lab results
				Health information such as weight, blood pressure, blood sugar
				Major health events such as heart attacks or serious accidents or injuries
				Past surgeries
				Doctors visits
				Hospitalizations
				Names and contact information of my health care providers
				Other, please specify	NU-3A1
	NU-3A1	What other health information do you keep track of?				Text area, no char limit		N	Skip Logic Group	NU-3A1
	NU-3B	Which of the following ways do your store your health information? (Check ALL that you use)		Paper files of my health information		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	NU-3A
				Files with health care bills and receipts
				Computer files of my health information
				Web-based electronic personal health records, including My HealtheVet
				A calendar where I keep track of appointments and other health information
				None of the above- My health care providers maintain all my medical records
				Other, please specify	NU-3B1
	NU-3B1	What other ways do you store information?				Text area, no char limit		N	Skip Logic Group	NU-3A2
	NU-3C	For what purposes do you keep track of this information? (Check ALL that apply.)		For my own use as a reminder of the care I have received		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	NU-3A
				To share with doctors
				To share with family members or friends who help take care of me
				For insurance purposes
				To monitor change in my health status over time (i.e. change in blood pressure)
				In case of emergency for family and care providers
				Other, please specify	NU-3C1
	NU-3C1	For what other purpose do you track this information?				Text area, no char limit		N	Skip Logic Group	NU-3A3
	NU-3D	On a scale from 1 to 5, how satisfied are you with your current system of organizing your health information?		1 - Not at all Satisfied		Radio button, one-up vertical	Single	Y	Skip Logic Group	NU-3A
				2 - A Little Satisfied
				3 - Somewhat Satisfied
				4 - Very Satisfied
				5 - Extremely Satisfied
	NU-4	Do you see any health care providers who are not affiliated with the VA?		No		Radio button, one-up vertical	Single	Y	Skip Logic Group	NU-4
				Yes	NU-4A, NU-4B
	NU-4A	How do your VA providers and non-VA providers communicate about your healthcare?		I share information between them		Radio button, one-up vertical	Single	Y	Skip Logic Group	NU-4A
				They exchange medical records via mail or fax
				They speak by phone
				I do not know how they communicate
				They do not communicate
				Other, please specify	NU-4A1
	NU-4A1	How else do you communicate?				Text area, no char limit		N	Skip Logic Group	NU-4A1
	NU-4B	How satisfied are you with the communication about your medications and health care between your VA providers and the providers outside of the VA?		1 - Not at all Satisfied		Radio button, one-up vertical	Single	Y	Skip Logic Group	NU-4A
				2 - A little Satisfied
				3 - Somewhat Satisfied
				4 - Very Satisfied
				5 - Extremely Satisfied
	NU-5	We are interested in learning what Veterans would like to help them better manage their health information. Which of the following features would you like to have in your current system for storing your health information? (Check ALL that apply.)		The ability to organize the information into specific categories (i.e. medications, doctors visits, hospitalizations, wellness checks, and preventive screens)		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	NU-5
				The ability to locate easily information about care I have received in the past
				The ability to send summaries of my health information electronically to caregivers, health care providers, or insurance companies
				The ability to store all my health information on a small portable disk or device so I can have it with me at all times
				Other, please specify	NU-5A
	NU-5A	What other feature are you interested in?				Text area, no char limit		N	Skip Logic Group	NU-5A
	NU-6A	We are interested in helping Veterans to use the Blue Button Feature of My HealtheVet. Please read the items below and indicate whether or not it would make it more likely that you would use the Blue Button. Would you be more likely to use the Blue Button if . . Your doctor, nurse, or other care provider strongly recommended you use the Blue Button?		I would still not use the Blue Button if this happened		Radio button, one-up vertical	Single	Y	Skip Logic Group	NU-6
				I might use the Blue Button if this happened
				I would definitely use the Blue Button if this happened.
	NU-6B	Another veteran strongly recommended you use the Blue Button?		I would still not use the Blue Button if this happened		Radio button, one-up vertical	Single	Y	Skip Logic Group	NU-6
				I might use the Blue Button if this happened
				I would definitely use the Blue Button if this happened.
	NU-6C	Using it would remind you of when your VA appointments are?		I would still not use the Blue Button if this happened		Radio button, one-up vertical	Single	Y	Skip Logic Group	NU-6
				I might use the Blue Button if this happened
				I would definitely use the Blue Button if this happened.
	NU-6D	Using it would make it easier for you to give others, such as health care providers or family members, important medical information?		I would still not use the Blue Button if this happened		Radio button, one-up vertical	Single	Y	Skip Logic Group	NU-6
				I might use the Blue Button if this happened
				I would definitely use the Blue Button if this happened.
	NU-6E	Using it would help you understand better which medications you need to be taking?		I would still not use the Blue Button if this happened		Radio button, one-up vertical	Single	Y	Skip Logic Group	NU-6
				I might use the Blue Button if this happened
				I would definitely use the Blue Button if this happened.
	NU-6F	Using it would make it easier for you to monitor lab results?		I would still not use the Blue Button if this happened		Radio button, one-up vertical	Single	Y	Skip Logic Group	NU-6
				I might use the Blue Button if this happened
				I would definitely use the Blue Button if this happened.
	NU-6G	Using it would help you better manage your health in general?		I would still not use the Blue Button if this happened		Radio button, one-up vertical	Single	Y	Skip Logic Group	NU-6
				I might use the Blue Button if this happened
				I would definitely use the Blue Button if this happened.
	NU-6H	Would you be more likely to use the VA Blue Button if...A VA staff member showed you how to use it?		I would still not use the Blue Button if this happened		Radio button, one-up vertical	Single	Y	Skip Logic Group	NU-6
				I might use the Blue Button if this happened
				I would definitely use the Blue Button if this happened.
	NU-6I	There was an easy-to-follow booklet showing you how to use it?		I would still not use the Blue Button if this happened		Radio button, one-up vertical	Single	Y	Skip Logic Group	NU-6
				I might use the Blue Button if this happened
				I would definitely use the Blue Button if this happened.
	NU-7	Please indicate below whether or not you intend to use the Blue Button feature in the future.		I will not use the Blue Button in the future.		Radio button, one-up vertical	Single	Y	Skip Logic Group	NU-7
				I might use the Blue Button in the future.
				I will definitely use the Blue Button in the future.
	NR-1	We are interested in learning about Veterans who have used the Blue Button, but do not plan to use it again. Why do you no longer use the Blue Button Feature of My HealtheVet? (Check ALL that apply)		I did not know how to use it		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	NR-1
				I could not find what I was looking for	NR-1A
				The information in the file/print out was not useful	NR-1A
				The file/print out was too long
				I would rather use another way to store my health information
				Other, please specify	NR-1A1
	NR-1A1	What other reason do you no longer use the Blue Button?				Text area, no char limit		N	Skip Logic Group	NR-1A1
	NR-1A	What information did you want to find on the Blue Button file? (Check ALL that apply.)		My entire medical record		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	NR-1A
				My health record from my military service
				My lab results
				My appointments
				Other, please specify	NR-1A2
	NR-1A2	What other information did you want to find?				Text area, no char limit		N	Skip Logic Group	NR-1A2
	NR2	In the past year, My HealtheVet has expanded to include lab results, and appointments. Had you heard about these new features of the Blue Button?		No	NR-2A	Radio button, one-up vertical	Single	Y	Skip Logic Group	NR2
				Yes
	NR-2A	Would the ability to view labs and appointments make you more likely to use the Blue Button?		No		Radio button, one-up vertical	Single	Y	Skip Logic Group	NR-2A
				Yes
	NR-3	We are interested in how veterans keep a record of their health information. On a scale from 1 to 5, how important to you is keeping your own record of your personal health information?		1 - Not at all Important		Radio button, one-up vertical	Single	Y	Skip Logic Group	NR-3
				2 - A little Important
				3 - Somewhat Important
				4 - Very Important
				5 - Extremely important
	NR-4	Do you have a system for organizing your health information?		No		Radio button, one-up vertical	Single	Y	Skip Logic Group	NR-4
				Yes	NR-4A, NR-4B, NR -4C, NR-4D
	NR-4A	What health information do you keep track of? (Check ALL that apply)		My current prescription medications		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	NR-4A
				Supplements, vitamins, and over-the-counter medications I am taking.
				Medications I have taken in the past
				Lab results
				Health information such as weight, blood pressure, blood sugar
				Major health events such as heart attacks or serious accidents or injuries
				Past surgeries
				Doctors visits
				Hospitalizations
				Names and contact information of my health care providers
				Other, please specify	NR-4A1
	NR-4A1	What other information do you keep track of?				Text area, no char limit		N	Skip Logic Group	NR-4A1
	NR-4B	Which of the following ways do your store your health information? (Check ALL that you use)		Paper files of my health information		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	NR-4A
				Files with health care bills and receipts
				Computer files of my health information
				Web-based electronic personal health records, including My HealtheVet
				A calendar where I keep track of appointments and other health information
				None of the above- My health care providers maintain all my medical records
				Other, please specify	NR-4A2
	NR-4A2	What other ways do you store your information?				Text area, no char limit		N	Skip Logic Group	NR-4A2
	NR-4C	For what purposes do you keep track of this information?(Check ALL that apply.)		For my own use as a reminder of the care I have received		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	NR-4A
				To share with doctors
				To share with family members or friends who help take care of me
				For insurance purposes
				To monitor change in my health status over time (i.e. change in blood pressure)
				In case of emergency for family and care providers
				Other, please specify	NR-4A3
	NR-4A3	For what other purposes do you track this information?				Text area, no char limit		N	Skip Logic Group	NR-4A3
	NR-4D	On a scale from 1 to 5, how satisfied are you with your current system of organizing your health information?		1 - Not at all Satisfied		Radio button, one-up vertical	Single	Y	Skip Logic Group	NR-4A
				2 - A Little Satisfied
				3 - Somewhat Satisfied
				4 - Very Satisfied
				5 - Extremely Satisfied
	NR-5	Do you see any health care providers who are not affiliated with the VA?		No		Radio button, one-up vertical	Single	Y	Skip Logic Group	NR-5
				Yes	NR-5A, NR-5B
	NR-5A	How do your VA providers and non-VA providers communicate about your healthcare?		I share information between them		Radio button, one-up vertical	Single	Y	Skip Logic Group	NR-5A
				They exchange medical records via mail or fax
				They speak by phone
				I do not know how they communicate
				They do not communicate
				Other: Please Describe	NR-5A1
	NR-5A1	Other communication method				Text area, no char limit		N	Skip Logic Group	NR-5A1
	NR-5B	How satisfied are you with the communication about your medications and health care between your VA providers and the providers outside of the VA?		1 - Not at all Satisfied		Radio button, one-up vertical	Single	Y		NR-5A
				2 - A little Satisfied
				3 - Somewhat Satisfied
				4 - Very Satisfied
				5 - Extremely Satisfied
	NR-6	We are interested in learning what Veterans would like to help them better manage their health information. Which of the following features would you like to have in your current system for storing your health information? (Check ALL that apply.)		The ability to organize the information into specific categories (i.e. medications, doctors visits, hospitalizations, wellness checks, and preventive screens)		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	NR-6
				The ability to locate easily information about care I have received in the past
				The ability to send summaries of my health information electronically to caregivers, health care providers, or insurance companies
				The ability to store all my health information on a small portable disk or device so I can have it with me at all times
				Other, please specify	NR-6A
	NR-6A	What other feature would you like to have?				Text area, no char limit		N	Skip Logic Group	NR-6A
	NR-7A	We are interested in helping Veterans to use the Blue Button Feature of My HealtheVet. Please read the items below and indicate whether or not it would make it more likely that you would use the Blue Button. Would you be more likely to use the Blue Button if . . Your doctor, nurse, or other care provider strongly recommended you use the Blue Button?		I would still not use the Blue Button if this happened		Radio button, one-up vertical	Single	Y		NR-7
				I might use the Blue Button if this happened
				I would definitely use the Blue Button if this happened.
	NR-7B	Another veteran strongly recommended you use the Blue Button?		I would still not use the Blue Button if this happened		Radio button, one-up vertical	Single	Y	Skip Logic Group	NR-7
				I might use the Blue Button if this happened
				I would definitely use the Blue Button if this happened.
	NR-7C	Using it would remind you of when your VA appointments are?		I would still not use the Blue Button if this happened		Radio button, one-up vertical	Single	Y	Skip Logic Group	NR-7
				I might use the Blue Button if this happened
				I would definitely use the Blue Button if this happened.
	NR-7D	Using it would make it easier for you to give others, such as health care providers or family members, important medical information?		I would still not use the Blue Button if this happened		Radio button, one-up vertical	Single	Y	Skip Logic Group	NR-7
				I might use the Blue Button if this happened
				I would definitely use the Blue Button if this happened.
	NR-7E	Using it would help you understand better which medications you need to be taking?		I would still not use the Blue Button if this happened		Radio button, one-up vertical	Single	Y	Skip Logic Group	NR-7
				I might use the Blue Button if this happened
				I would definitely use the Blue Button if this happened.
	NR-7F	Using it would make it easier for you to monitor lab results?		I would still not use the Blue Button if this happened		Radio button, one-up vertical	Single	Y	Skip Logic Group	NR-7
				I might use the Blue Button if this happened
				I would definitely use the Blue Button if this happened.
	NR-7G	Using it would help you better manage your health in general?		I would still not use the Blue Button if this happened		Radio button, one-up vertical	Single	Y	Skip Logic Group	NR-7
				I might use the Blue Button if this happened
				I would definitely use the Blue Button if this happened.
	NU-8	Please indicate below whether or not you intend to use the Blue Button feature in the future.		I will not use the Blue Button in the future.		Radio button, one-up vertical	Single	Y	Skip Logic Group	NU-8
				I might use the Blue Button in the future.
				I will definitely use the Blue Button in the future.
				I use it to view my health information on the My HealtheVet website		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	CU-1
			I use it to create an electronic file of my health information (for example, saved a file to your computer)
			I print a paper copy of my health information
	CU-2	What information were you interested in when getting your health information through the Blue Button? ( Check ALL that apply)		My current VA medication list		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	CU-2
				My entire VA medication history (all medications prescribed for me while I have been a patient at the VA)
				My lab results
				My list of medications prescribed outside of the VA (self-entered in My HealtheVet)
				My list of over-the-counter, supplement, or herbal medications (self-entered in MyHealtheVet)
				A list of my providers and their contact information (self-entered into My HealtheVet)
				Other, please specify	CU-2A
	CU-2A	What other information were you interested in?				Text area, no char limit		N	Skip Logic Group	CU-2A
	CU-3	What did you do with your Blue Button print out or file? (Check ALL that apply)		I saved it for my records		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	CU-3
				I read it
				I shared it (or plan to share it) with my VA health care provider	CU-3A, CU-3B, CU-3C
				I shared it (or plan to share it) with my spouse, child, or other family member
				I shared it (or plan to share it) with my non-VA health care provider	CU-3A, CU-3B, CU-3C
				I did not keep the information (for example, deleted the file or threw away the print copy)
				Other, please specify	CU-3A1
	CU-3A1	What else did you do with your Blue Button print out or file?				Text area, no char limit		N	Skip Logic Group	CU-3A1
	CU-3A	What information on the Blue Button print out did you want to show your care provider? (Check ALL that apply)		My current V A medication list		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	CU-3A
				My entire VA medication history
				My lab results
				My list of medications prescribed outside of the VA (self-entered in My HealtheVet)
				My list of over-the-counter, supplement, or herbal medications (self-entered in MyHealtheVet)
				Other, please specify	CU-3A2
	CU-3A2	What other information did you want to show your provider?				Text area, no char limit		N	Skip Logic Group	CU-3A2
	CU-3B	What did your provider do with the Blue Button print out? Check ALL that apply.		He or she used it to review my complete medication list		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	CU-3A
				He or she used it to review recent lab results
				He or she used it to find other health information
				He or she filed it in my medical record
				He or she did not look at it
				Other, please specify	CU-3A3
	CU-3A3	What else did your provider do with the printout?				Text area, no char limit		N	Skip Logic Group	CU-3A3
	CU-3C	How helpful do you think your care provider found the Blue Button information in making decisions about your care?		Not at All Helpful		Radio button, one-up vertical	Single	Y	Skip Logic Group	CU-3A
				Somewhat Helpful
				Very helpful
				Don’t Know
	CU-4	We are interested in how veterans keep a record of their health information. On a scale from 1 to 5, how important to you is keeping your own record of your personal health information?		1 - Not at all Important		Radio button, one-up vertical	Single	Y	Skip Logic Group	CU-4
				2 - A little Important
				3 - Somewhat Important
				4 - Very Important
				5 - Extremely important
	CU-5	Do you have a system for organizing your health information?		No		Radio button, one-up vertical	Single	Y	Skip Logic Group	CU-5
				Yes	CU-5A, CU-5B
	CU-5A	What health information do you keep track of? (Check ALL that apply)		My current prescription medications		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	CU-5A
				Supplements, vitamins, and over-the-counter medications I am taking.
				Medications I have taken in the past
				Lab results
				Health information such as weight, blood pressure, blood sugar
				Major health events such as heart attacks or serious accidents or injuries
				Past surgeries
				Doctors visits
				Hospitalizations
				Names and contact information of my health care providers
				Other, please specify	CU-5A1
	CU-5A1	What other health information do you keep track of?				Text area, no char limit		N	Skip Logic Group	CU-5A1
	CU-5B	Which of the following ways do your store your health information? (Check ALL that you use)		Paper files of my health information		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	CU-5A
				Files with health care bills and receipts
				Computer files of my health information
				Web-based electronic personal health records, including My HealtheVet
				A calendar where I keep track of appointments and other health information
				None of the above- My health care providers maintain all my medical records
				Other, please specify	CU-5B1
	CU-5B1	What other was do you store your health information?				Text area, no char limit		N	Skip Logic Group	CU-5A2
	CU-6	Do you see any health care providers who are not affiliated with the VA?		No		Radio button, one-up vertical	Single	Y		CU-6
				Yes	CU-6A, CU-6B, CU-6C, CU-6D
	CU-6A	How do your VA providers and non-VA providers communicate about your healthcare?		I share information between them		Radio button, one-up vertical	Single	Y	Skip Logic Group	CU-6A
				They exchange medical records via mail or fax
				They speak by phone
				I do not know how they communicate
				They do not communicate
				Other, please specify	CU-6A1
	CU-6A1	How else do your providers communicated about your healthcare?				Text area, no char limit		N	Skip Logic Group	CU-6A1
	CU-6B	How satisfied are you with the communication about your medications and health care between your VA providers and the providers outside of the VA?		1 - Not at all Satisfied		Radio button, one-up vertical	Single	Y	Skip Logic Group	CU-6A
				2 - A little Satisfied
				3 - Somewhat Satisfied
				4 - Very Satisfied
				5 - Completely Satisfied
	CU-6C	Have you ever shared the Blue Button print out with your non-VA providers?		No		Radio button, one-up vertical	Single	Y	Skip Logic Group	CU-6A
				Yes	CU-6D
	CU-6D	How helpful do you think your non-VA care provider found the Blue Button information in making decisions about your care?		Not at All Helpful		Radio button, one-up vertical	Single	Y	Skip Logic Group	CU-6A
				Somewhat Helpful
				Very helpful
				Don’t Know
	CU-7A	Please indicate whether or not you agree with the following statements using a scale from 1 (Completely Disagree) to 5 (Completely Agree). The Blue Button feature helps me remember when my VA appointments are.		1 - Completely Disagree		Radio button, one-up vertical	Single	Y	Skip Logic Group	CU-7
				2 - Somewhat Disagree
				3 - Neither Agree nor Disagree
				4 - Somewhat Agree
				5 - Completely Agree
	CU-7B	The Blue Button feature helps me understand my health history better because all the information is in one place.		1 - Completely Disagree		Radio button, one-up vertical	Single	Y	Skip Logic Group	CU-7
				2 - Somewhat Disagree
				3 - Neither Agree nor Disagree
				4 - Somewhat Agree
				5 - Completely Agree
	CU-7C	The Blue Button feature makes it easier for me to give others, such as health care providers or family members, important medical information?		1 - Completely Disagree		Radio button, one-up vertical	Single	Y	Skip Logic Group	CU-7
				2 - Somewhat Disagree
				3 - Neither Agree nor Disagree
				4 - Somewhat Agree
				5 - Completely Agree
	CU-7D	The Blue Button feature helps me understand better which medications I need to be taking.		1 - Completely Disagree		Radio button, one-up vertical	Single	Y	Skip Logic Group	CU-7
				2 - Somewhat Disagree
				3 - Neither Agree nor Disagree
				4 - Somewhat Agree
				5 - Completely Agree
	CU-7E	The Blue Button feature makes it easier to monitor lab results.		1 - Completely Disagree		Radio button, one-up vertical	Single	Y	Skip Logic Group	CU-7
				2 - Somewhat Disagree
				3 - Neither Agree nor Disagree
				4 - Somewhat Agree
				5 - Completely Agree
	CU-7F	The Blue Button feature has helped me better manage my health in general.		1 - Completely Disagree		Radio button, one-up vertical	Single	Y	Skip Logic Group	CU-7
				2 - Somewhat Disagree
				3 - Neither Agree nor Disagree
				4 - Somewhat Agree
				5 - Completely Agree
	CU-8	On a scale from 1 to 10 with 1 being “Not at All Satisfied” and 10 being “Extremely Satisfied”, please rate your overall satisfaction with the Blue Button Feature of My HealtheVet?		1 - Not at all Satisfied		Radion button, scale, no don't know	Single	Y	Skip Logic Group	CU-8
				2
				3
				4
				5 - Somewhat Satisfied
				6
				7
				8
				9
				10 - Extremely Satisfied
	CU-9	Please indicate below whether or not you intend to use the Blue Button feature in the future.		I will not use the Blue Button in the future.		Drop down, select one	Single	Y	Skip Logic Group	CU-9
				I might use the Blue Button in the future.
				I will definitely use the Blue Button in the future.
RJB00026		Are you a registered user on the MyHealtheVet web site?		Yes		Dropdown (Select-one)	Single	Y
				No
				Not sure
RJB00027		Have you visited your VA Facility in person to show your ID and be "in-person authenticated" (IPA) for My HealtheVet?		Yes		Dropdown (Select-one)	Single	Y
				No
				Not sure
				Not applicable
EDO07291		Did you use a VA medical facility or service for any of your health care needs in the last 12 months?	EDO07291A001	Yes		Dropdown (Select-one)	Single	Y
			EDO07291A002	No
RJB00029		My use of the My HealtheVet personal health record has improved my ability to manage my health.		Strongly agree		Drop down, select one	Single	Y
				Agree
				Not sure
				Disagree
				Strongly disagree
				Not applicable
ALM0173		What is the main improvement that you would suggest for the My HealtheVet web site?				Open-ended	Single	N
AED02714		What is your age range?		Under 20		Dropdown (Select-one)	Single	N
				20-24
				25-29
				30-34
				35-39
				40-44
				45-49
				50-54
				55-59
				60-64
				65-69
				70-74
				75-79
				80-84
				85 or older
JIC00267		What is your gender?		Male		Dropdown (Select-one)	Single	N
				Female
JIC00178		In general, how would you rate your overall health?		Excellent		Dropdown (Select-one)	Single	Y
				Very Good
				Good
				Fair
				Poor
		Do you have any of the following health problems? (check all that apply)		Prefer not to answer		Checkbox, one-up vertical	Multi	Y		Health Problems
				Diabetes
				High Blood Pressure
				High Cholesterol
				Heart Disease
				Previous Heart Attack
				Heart Failure
				Lung Disease/Asthma
				Spinal Cord Injury
				Arthritis of any kind
				Cancer
				Mental Health Problems
				Orthopedic Problems
				Ulcer or Stomach Disease
				Pain
				Anemia or other Blood Disease
				None of the above
RJB00080		Please rate your ability in using the Internet:		Beginner or novice (just starting/don't use Internet much)		Radio button, one-up vertical	Single	Y		Internet Ability
REINSTATING				Intermediate (use the Internet for a few things)
				Advanced (frequently use Internet & search for information)
		Which of the following social media sites or tools have you used in the last 2 months? (Check all that apply)		VA Sponsored Facebook page	AA	Checkbox, one-up vertical	Multi	Y		Social Media Usage
				VA sponsored Twitter accounts	BB
				VA Sponsored Blogs	CC
				VA Sponsored YouTube Channel	DD
				Facebook	EE
				Twitter	FF
				My Space	GG
				YouTube	HH
				Blogs	II
				Other, please specify:	A
				None
	A	What other social media tools have you used?				Text area, no char limit
	AA	Did the VA Sponsored Facebook page provide you with information that made you want to visit and use My HealtheVet?		Yes		Radio button, one-up vertical	Single	Y		MHV Use - VA Facebook
				No
	BB	Did the VA sponsored Twitter accounts provide you with information that made you want to visit and use My HealtheVet?		Yes		Radio button, one-up vertical	Single	Y		MHV Use - VA Twitter
				No
	CC	Did the VA Sponsored Blogs provide you with information that made you want to visit and use My HealtheVet?		Yes		Radio button, one-up vertical	Single	Y		MHV Use - VA Blog
				No
	DD	Did the VA Sponsored YouTube Channel provide you with information that made you want to visit and use My HealtheVet?		Yes		Radio button, one-up vertical	Single	Y		MHV Use - VA YouTube
				No
	EE	Did Facebook provide you with information that made you want to visit and use My HealtheVet?		Yes		Radio button, one-up vertical	Single	Y		MHV Use - Facebook
				No
	FF	Did Twitter provide you with information that made you want to visit and use My HealtheVet?		Yes		Radio button, one-up vertical	Single	Y		MHV Use - Twitter
				No
	GG	Did MySpace provide you with information that made you want to visit and use My HealtheVet?		Yes		Radio button, one-up vertical	Single	Y		MHV Use - MySpace
				No
	HH	Did the Blogs provide you with information that made you want to visit and use My HealtheVet?		Yes		Radio button, one-up vertical	Single	Y		MHV Use - Blogs
				No
	II	Did YouTube provide you with information that made you want to visit and use My HealtheVet?		Yes		Radio button, one-up vertical	Single	Y		MHV Use - YouTube
				No
AED06379		Have you completed this survey within the past 3 months?		Yes		Radio button, one-up vertical
				No			Single	N
				Don't recall

---

Sheet 18: Custom Qsts 4-20-11

Model Instance Name: VA - My HealtheVet			red & strike-through: DELETE
MID:	NJxFtMU9UosBkJZRd48x9Q==		underlined & italicized: RE-ORDER
			pink: ADDITION
Date:	6/23/2009		blue + -->: REWORDING
			violet (bold): SKIP-LOGIC
MID: CUSTOM QUESTION LIST
QID	Skip Logic Label	Question Text	Answer Choices (limited to 50 characters)	Skip to	Type (select from list)	Single or Multi	Required Y/N	Question Label
ALM0169		How frequently do you visit the My HealtheVet web site?	First time		Dropdown (Select-one)	Single	Y
			Daily
			More than once a day
			About once a week
			About once a month
			About every 6 months
			Less than every 6 months
ALM0170		Which of the following best describes you?	Active duty		Checkbox, one-up vertical	Multi	Y
			Veteran
			Family member of a veteran
			Veteran service organization
			News media
			General public
			VA employee
			Federal government employee
			State/local government employee
			Other role
RJB00048		Please indicate your military period(s) of service:	Global War on Terror (OEF/OIF)		Check-boxes	Multi	N
			Desert Shield/Desert Storm
			Vietnam War
			Korean War
			World War II
			Peacetime Service
			Other
			Not Applicable
RJB00022		What were you trying to accomplish today in My HealtheVet? (please select all that apply)	Enter/keep track of personal information (My Caregivers, etc.)		Check-boxes	Multi	Y
			Enter/keep track of personal health care information (blood pressure, blood sugar, etc.)
			Look up information about a medication
			Request a prescription refill
			Access prescription history from my VA medical record
			Download my data using the VA Blue Button_x000D_
			Learn about what features are available_x000D_
			View my VA Appointments
			Find a VA health care facility
			Research a health condition
			Find information about VA Benefits
			Other (please specify)	A
RJB00022other	A	Other - trying to accomplish			Text field, <100 char	Single	N
ALM0172		Did you accomplish what you wanted to in My HealtheVet?	Yes		Dropdown (Select-one)	Single	Y
			No
			Partially
			Not finished yet
RJB00026		Are you a registered user on the MyHealtheVet web site?	Yes		Dropdown (Select-one)	Single	Y
			No
			Not sure
RJB00027		Have you visited your VA Facility in person to show your ID and be "in-person authenticated" (IPA) for My HealtheVet?	Yes		Dropdown (Select-one)	Single	Y
			No
			Not sure
			Not applicable
EDO07291		Did you use a VA medical facility or service for any of your health care needs in the last 12 months?	Yes		Dropdown (Select-one)	Single	Y
			No
EDO07292		The “VA Blue Button: Download My Data” feature was recently added to My HealtheVet. Have you ever used this VA Blue Button feature?	Yes	A, B, C, D, E, F	Drop down, select one	Single	Y
			No	G
			Not sure
EDO07293	G	Why have you not used the VA Blue Button? (Check all that apply)	I was not aware of it		Checkbox, one-up vertical	Multi	Y
			I did not know how to use it
			I did not think it would be useful
			I want to learn more about it before I use it
			I was concerned about privacy or the security of my personal health information
			Other, please specify	G2
EDO07294	G2	Why else did you not use the VA Blue Button?			Text area, no char limit		Y
EDO07295	A	How did you hear about the VA Blue Button? (Check all that apply)	I read about it on the My HealtheVet website		Checkbox, one-up vertical	Multi	Y
			I saw the Blue Button icon on the My HealtheVet website
			I saw or heard it promoted at a VA facility
			From a VA staff member
			From my VA health care provider
			From another Veteran
			From a member of a Veteran Service Organization
			I read about it in the news or on another website
			Other, please specify	A2
EDO07296	A2	How else did you hear about the VA Blue Button?			Text area, no char limit		Y
EDO07297	B	How many times have you used the VA Blue Button?	Once		Drop down, select one	Single	Y
			More than once	B2, B3
			Not sure
			Never
EDO07298	B2	About how many times have you used the VA Blue Button?			Text area, no char limit		Y
EDO07299	B3	For what purposes have you used it more than once?			Text area, no char limit		Y
EDO07300	C	How did you use the VA Blue Button? (Check all that apply)	I used it to view my personal health information on the My HealtheVet website		Checkbox, one-up vertical	Multi	Y
			I printed a paper copy of my personal health information using the Print button	C2
			I used the download button to create a text file of my personal health information	C4
EDO07301	C2	What did you do with the printed paper copy of your personal health information? (Check all that apply)	I read it		Checkbox, one-up vertical	Multi	Y
			I saved it for my records
			I shared it (or plan to share it) with my VA health care provider
			I shared it (or plan to share it) with my Non-VA health care provider
			I shared it (or plan to share it) with my spouse, child, or other family member
			I discarded it
			Other, please specify	C3
EDO07302	C3	What else did you do with the printed paper copy?			Text area, no char limit		Y
EDO07303	C4	What did you do with the Blue Button file containing your personal health information? (Check all that apply)	I saved it to my computer		Checkbox, one-up vertical	Multi	Y
			I stored the file on a CD, portable drive, or other media
			I uploaded the file to another website or software system
			I added the information to another personal health record
			I shared it (or plan to share it) with my VA health care provider
			I shared it (or plan to share it) with my Non-VA health care provider
			I shared it (or plan to share it) with my spouse, child, or other family member
			I deleted it
			I was not able to locate the file
			Nothing
			Other, please specify	C5
EDO07304	C5	What else did you do with the Blue Button file?			Text area, no char limit		Y
EDO07305	D	Did you make any changes to the VA Blue Button file such as adding, changing, or removing information?	Yes		Drop down, select one	Single	Y
			No
			Not sure
EDO07306	E	What did you find useful about your use of the VA Blue Button (Check all that apply)	Having my VA personal health information in one place		Checkbox, one-up vertical	Multi	Y
			Having an electronic file of my VA personal health information
			Being able to share a copy of my VA personal health information with someone else
			Being able to edit the copy of my personal health information
			Other, please specify	E2
			Did not find it useful
EDO07307	E2	What else did you find useful about the VA Blue Button?			Text area, no char limit		Y
EDO07308	F	What information in the VA Blue Button file was most useful? (Check all that apply	My self-entered information		Checkbox, one-up vertical	Multi	Y
			My HealtheVet Account Summary
			My VA Medication History (available to In-Person Authenticated veterans)
			My VA Wellness Reminders (available to In-Person Authenticated veterans)
			Other, please specify	F2
EDO07309	F2	What information was most useful?			Text area, no char limit		Y
EDO07310		What additional features would you find useful if added to the VA Blue Button? (Check all that apply)	Being able to include additional kinds of information as it becomes available in My HealtheVet, such as VA lab test results		Checkbox, one-up vertical	Multi	Y
			Being able to select a date range for the data included in my VA Blue Button download
			Being able to pick which portions of my personal health information are included in my VA Blue Button download
			Being able to transfer my personal health information to a non-VA personal health record or application
			Being able to access the information on other devices (for example a portable drive or mobile device)
			Being able to choose the format of the VA Blue Button file
			Other, please specify	A
			None
EDO07311	A	What other features would you find useful?			Text area, no char limit		Y
EDO07312		About how often do you plan to download your personal health information using the VA Blue Button?	One time only		Radio button, one-up vertical	Singly	Y
			About once a month
			About once every three months
			About once every six months
			About once a year
			Less frequently than once a year
			Only when I have a VA health care visit
			Other, please specify	A
			Not sure
			Never
EDO07313	A	How often do you plan to download your information?					Y
EDO07314		How can you see yourself using the VA Blue Button download in the future? (Check all that apply)	Save the information to another place (for example, by copying to a file on my computer)		Radio button, one-up vertical	Multi	Y
			Share the information with a family member or friend
			Share the information with my VA health care provider
			Share the information with my Non-VA health care provider
			Use the information with another program (for example, to check for drug interactions)
			Put the information into another Personal Health Record
			Put the information in another website (for example, to receive customized care recommendations or to apply other kinds of tools to my personal health information)
			I do not plan to use the VA Blue Button
			Not sure
EDO07315		Veterans who have completed In-Person Authentication (IPA) can download additional information using the VA Blue Button, including their VA Medication History and VA Wellness Reminders. Do you plan to complete In-Person Authentication in order to have access to this additional information?	Yes		Drop down, select one	Single	Y
			No, I am already In-Person Authenticated
			No
			Not sure
RJB00029		My use of the My HealtheVet personal health record has improved my ability to manage my health.	Strongly agree		Drop down, select one	Single	Y
			Agree
			Not sure
			Disagree
			Strongly disagree
			Not applicable
ALM0173		What is the main improvement that you would suggest for the My HealtheVet web site?			Open-ended	Single	N
KFB04531		The My HealtheVet website provides articles on topics of interest to Veterans. What topics are you most interested in for upcoming articles?			Text area, no char limit	Single	N
AED02714		What is your age range?	Under 20		Dropdown (Select-one)	Single	N
			20-24
			25-29
			30-34
			35-39
			40-44
			45-49
			50-54
			55-59
			60-64
			65-69
			70-74
			75-79
			80-84
			85 or older
JIC00267		What is your gender?	Male		Dropdown (Select-one)	Single	N
			Female
JIC00178		In general, how would you rate your overall health?	Excellent		Dropdown (Select-one)	Single	Y
			Very Good
			Good
			Fair
			Poor
AED06379		Have you completed this survey within the past 3 months?	Yes		Radio button, one-up vertical
			No			Single	N
			Don't recall

---

Sheet 19: Custom Qsts 1-10-11

Model Instance Name: VA - My HealtheVet			red & strike-through: DELETE
MID:	NJxFtMU9UosBkJZRd48x9Q==		underlined & italicized: RE-ORDER
			pink: ADDITION
Date:	6/23/2009		blue + -->: REWORDING
			violet (bold): SKIP-LOGIC
MID: CUSTOM QUESTION LIST
QID	Skip Logic Label	Question Text	Answer Choices (limited to 50 characters)	Skip to	Type (select from list)	Single or Multi	Required Y/N	Question Label
ALM0169		How frequently do you visit the My HealtheVet web site?	First time		Dropdown (Select-one)	Single	Y
			Daily
			More than once a day
			About once a week
			About once a month
			About every 6 months
			Less than every 6 months
ALM0170		Which of the following best describes you?	Active duty		Checkbox, one-up vertical	Multi	Y
			Veteran
			Family member of a veteran
			Veteran service organization
			News media
			General public
			VA employee
			Federal government employee
			State/local government employee
			Other role
RJB00048		Please indicate your military period(s) of service:	Global War on Terror (OEF/OIF)		Check-boxes	Multi	N
			Desert Shield/Desert Storm
			Vietnam War
			Korean War
			World War II
			Peacetime Service
			Other
			Not Applicable
RJB00022		What were you trying to accomplish today in My HealtheVet? (please select all that apply)	Enter/keep track of personal information (My Caregivers, etc.)		Check-boxes	Multi	Y
			Enter/keep track of personal health care information (blood pressure, blood sugar, etc.)
			Look up information about a medication
			Request a prescription refill
			Access prescription history from my VA medical record
			Download my data using the VA Blue Button_x000D_
			Learn about what features are available_x000D_
			View my VA Appointments
			Find a VA health care facility
			Research a health condition
			Find information about VA Benefits
			Other (please specify)	A
RJB00022other	A	Other - trying to accomplish			Text field, <100 char	Single	N
ALM0172		Did you accomplish what you wanted to in My HealtheVet?	Yes		Dropdown (Select-one)	Single	Y
			No
			Partially
			Not finished yet
RJB00026		Are you a registered user on the MyHealtheVet web site?	Yes		Dropdown (Select-one)	Single	Y
			No
			Not sure
RJB00027		Have you visited your VA Facility in person to show your ID and be "in-person authenticated" (IPA) for My HealtheVet?	Yes		Dropdown (Select-one)	Single	Y
			No
			Not sure
			Not applicable
EDO07291		Did you use a VA medical facility or service for any of your health care needs in the last 12 months?	Yes		Dropdown (Select-one)	Single	Y
			No
EDO07292		The “VA Blue Button: Download My Data” feature was recently added to My HealtheVet. Have you ever used this VA Blue Button feature?	Yes	A, B, C, D, E, F	Drop down, select one	Single	Y
			No	G
			Not sure
EDO07293	G	Why have you not used the VA Blue Button? (Check all that apply)	I was not aware of it		Checkbox, one-up vertical	Multi	Y
			I did not know how to use it
			I did not think it would be useful
			I want to learn more about it before I use it
			I was concerned about privacy or the security of my personal health information
			Other, please specify	G2
EDO07294	G2	Why else did you not use the VA Blue Button?			Text area, no char limit		Y
EDO07295	A	How did you hear about the VA Blue Button? (Check all that apply)	I read about it on the My HealtheVet website		Checkbox, one-up vertical	Multi	Y
			I saw the Blue Button icon on the My HealtheVet website
			I saw or heard it promoted at a VA facility
			From a VA staff member
			From my VA health care provider
			From another Veteran
			From a member of a Veteran Service Organization
			I read about it in the news or on another website
			Other, please specify	A2
EDO07296	A2	How else did you hear about the VA Blue Button?			Text area, no char limit		Y
EDO07297	B	How many times have you used the VA Blue Button?	Once		Drop down, select one	Single	Y
			More than once	B2, B3
			Not sure
			Never
EDO07298	B2	About how many times have you used the VA Blue Button?			Text area, no char limit		Y
EDO07299	B3	For what purposes have you used it more than once?			Text area, no char limit		Y
EDO07300	C	How did you use the VA Blue Button? (Check all that apply)	I used it to view my personal health information on the My HealtheVet website		Checkbox, one-up vertical	Multi	Y
			I printed a paper copy of my personal health information using the Print button	C2
			I used the download button to create a text file of my personal health information	C4
EDO07301	C2	What did you do with the printed paper copy of your personal health information? (Check all that apply)	I read it		Checkbox, one-up vertical	Multi	Y
			I saved it for my records
			I shared it (or plan to share it) with my VA health care provider
			I shared it (or plan to share it) with my Non-VA health care provider
			I shared it (or plan to share it) with my spouse, child, or other family member
			I discarded it
			Other, please specify	C3
EDO07302	C3	What else did you do with the printed paper copy?			Text area, no char limit		Y
EDO07303	C4	What did you do with the Blue Button file containing your personal health information? (Check all that apply)	I saved it to my computer		Checkbox, one-up vertical	Multi	Y
			I stored the file on a CD, portable drive, or other media
			I uploaded the file to another website or software system
			I added the information to another personal health record
			I shared it (or plan to share it) with my VA health care provider
			I shared it (or plan to share it) with my Non-VA health care provider
			I shared it (or plan to share it) with my spouse, child, or other family member
			I deleted it
			I was not able to locate the file
			Nothing
			Other, please specify	C5
EDO07304	C5	What else did you do with the Blue Button file?			Text area, no char limit		Y
EDO07305	D	Did you make any changes to the VA Blue Button file such as adding, changing, or removing information?	Yes		Drop down, select one	Single	Y
			No
			Not sure
EDO07306	E	What did you find useful about your use of the VA Blue Button (Check all that apply)	Having my VA personal health information in one place		Checkbox, one-up vertical	Multi	Y
			Having an electronic file of my VA personal health information
			Being able to share a copy of my VA personal health information with someone else
			Being able to edit the copy of my personal health information
			Other, please specify	E2
			Did not find it useful
EDO07307	E2	What else did you find useful about the VA Blue Button?			Text area, no char limit		Y
EDO07308	F	What information in the VA Blue Button file was most useful? (Check all that apply	My self-entered information		Checkbox, one-up vertical	Multi	Y
			My HealtheVet Account Summary
			My VA Medication History (available to In-Person Authenticated veterans)
			My VA Wellness Reminders (available to In-Person Authenticated veterans)
			Other, please specify	F2
EDO07309	F2	What information was most useful?			Text area, no char limit		Y
EDO07310		What additional features would you find useful if added to the VA Blue Button? (Check all that apply)	Being able to include additional kinds of information as it becomes available in My HealtheVet, such as VA lab test results		Checkbox, one-up vertical	Multi	Y
			Being able to select a date range for the data included in my VA Blue Button download
			Being able to pick which portions of my personal health information are included in my VA Blue Button download
			Being able to transfer my personal health information to a non-VA personal health record or application
			Being able to access the information on other devices (for example a portable drive or mobile device)
			Being able to choose the format of the VA Blue Button file
			Other, please specify	A
			None
EDO07311	A	What other features would you find useful?			Text area, no char limit		Y
EDO07312		About how often do you plan to download your personal health information using the VA Blue Button?	One time only		Radio button, one-up vertical	Singly	Y
			About once a month
			About once every three months
			About once every six months
			About once a year
			Less frequently than once a year
			Only when I have a VA health care visit
			Other, please specify	A
			Not sure
			Never
EDO07313	A	How often do you plan to download your information?					Y
EDO07314		How can you see yourself using the VA Blue Button download in the future? (Check all that apply)	Save the information to another place (for example, by copying to a file on my computer)		Radio button, one-up vertical	Multi	Y
			Share the information with a family member or friend
			Share the information with my VA health care provider
			Share the information with my Non-VA health care provider
			Use the information with another program (for example, to check for drug interactions)
			Put the information into another Personal Health Record
			Put the information in another website (for example, to receive customized care recommendations or to apply other kinds of tools to my personal health information)
			I do not plan to use the VA Blue Button
			Not sure
EDO07315		Veterans who have completed In-Person Authentication (IPA) can download additional information using the VA Blue Button, including their VA Medication History and VA Wellness Reminders. Do you plan to complete In-Person Authentication in order to have access to this additional information?	Yes		Drop down, select one	Single	Y
			No, I am already In-Person Authenticated
			No
			Not sure
RJB00029		My use of the My HealtheVet personal health record has improved my ability to manage my health.	Strongly agree		Drop down, select one	Single	Y
			Agree
			Not sure
			Disagree
			Strongly disagree
			Not applicable
ALM0173		What is the main improvement that you would suggest for the My HealtheVet web site?			Open-ended	Single	N
KFB04531		The My HealtheVet website provides articles on topics of interest to Veterans. What topics are you most interested in for upcoming articles?			Text area, no char limit	Single	N
AED02714		What is your age range?	Under 20		Dropdown (Select-one)	Single	N
			20-24
			25-29
			30-34
			35-39
			40-44
			45-49
			50-54
			55-59
			60-64
			65-69
			70-74
			75-79
			80-84
			85 or older
JIC00267		What is your gender?	Male		Dropdown (Select-one)	Single	N
			Female
JIC00178		In general, how would you rate your overall health?	Excellent		Dropdown (Select-one)	Single	Y
			Very Good
			Good
			Fair
			Poor
AED06379		Have you completed this survey within the past 3 months?	Yes		Radio button, one-up vertical
			No			Single	N
			Don't recall

---

Sheet 20: Custom Qsts 10-22-10

Model Instance Name: VA - My HealtheVet			red & strike-through: DELETE
MID:	NJxFtMU9UosBkJZRd48x9Q==		underlined & italicized: RE-ORDER
			pink: ADDITION
Date:	6/23/2009		blue + -->: REWORDING
			violet (bold): SKIP-LOGIC
MID: CUSTOM QUESTION LIST
QID	Skip Logic Label	Question Text	Answer Choices (limited to 50 characters)	Skip to	Type (select from list)	Single or Multi	Required Y/N	Question Label
ALM0169		How frequently do you visit the My HealtheVet web site?	First time		Dropdown (Select-one)	Single	Y
			Daily
			More than once a day
			About once a week
			About once a month
			About every 6 months
			Less than every 6 months
ALM0170		Which of the following best describes you?	Active duty		Checkbox, one-up vertical	Multi	Y
			Veteran
			Family member of a veteran
			Veteran service organization
			News media
			General public
			VA employee
			Federal government employee
			State/local government employee
			Other role
RJB00048		Please indicate your military period(s) of service:	Global War on Terror (OEF/OIF)		Check-boxes	Multi	N
			Desert Shield/Desert Storm
			Vietnam War
			Korean War
			World War II
			Peacetime Service
			Other
			Not Applicable
RJB00022		What were you trying to accomplish today in My HealtheVet? (please select all that apply)	Enter/keep track of personal information (My Caregivers, etc.)		Check-boxes	Multi	Y
			Enter/keep track of personal health care information (blood pressure, blood sugar, etc.)
			Look up information about a medication
			Request a prescription refill
			Access prescription history from my VA medical record
			Find a VA health care facility
			Research a health condition
			Find information about VA Benefits
			Other (please specify)	A
RJB00022other	A	Other - trying to accomplish			Text field, <100 char	Single	N
ALM0172		Did you accomplish what you wanted to in My HealtheVet?	Yes		Dropdown (Select-one)	Single	Y
			No
			Partially
			Not finished yet
RJB00026		Are you a registered user on the MyHealtheVet web site?	Yes		Dropdown (Select-one)	Single	Y
			No
			Not sure
RJB00027		Have you visited your VA Facility in person to show your ID and be "in-person authenticated" (IPA) for My HealtheVet?	Yes		Dropdown (Select-one)	Single	Y
			No
			Not sure
			Not applicable
EDO07291		Did you use a VA medical facility or service for any of your health care needs in the last 12 months?	Yes		Dropdown (Select-one)	Single	Y
			No
EDO07292		The “VA Blue Button: Download My Data” feature was recently added to My HealtheVet. Have you ever used this VA Blue Button feature?	Yes	A, B, C, D, E, F	Drop down, select one	Single	Y
			No	G
			Not sure
EDO07293	G	Why have you not used the VA Blue Button? (Check all that apply)	I was not aware of it		Checkbox, one-up vertical	Multi	Y
			I did not know how to use it
			I did not think it would be useful
			I want to learn more about it before I use it
			I was concerned about privacy or the security of my personal health information
			Other, please specify	G2
EDO07294	G2	Why else did you not use the VA Blue Button?			Text area, no char limit		Y
EDO07295	A	How did you hear about the VA Blue Button? (Check all that apply)	I read about it on the My HealtheVet website		Checkbox, one-up vertical	Multi	Y
			I saw the Blue Button icon on the My HealtheVet website
			I saw or heard it promoted at a VA facility
			From a VA staff member
			From my VA health care provider
			From another Veteran
			From a member of a Veteran Service Organization
			I read about it in the news or on another website
			Other, please specify	A2
EDO07296	A2	How else did you hear about the VA Blue Button?			Text area, no char limit		Y
EDO07297	B	How many times have you used the VA Blue Button?	Once		Drop down, select one	Single	Y
			More than once	B2, B3
			Not sure
			Never
EDO07298	B2	About how many times have you used the VA Blue Button?			Text area, no char limit		Y
EDO07299	B3	For what purposes have you used it more than once?			Text area, no char limit		Y
EDO07300	C	How did you use the VA Blue Button? (Check all that apply)	I used it to view my personal health information on the My HealtheVet website		Checkbox, one-up vertical	Multi	Y
			I printed a paper copy of my personal health information using the Print button	C2
			I used the download button to create a text file of my personal health information	C4
EDO07301	C2	What did you do with the printed paper copy of your personal health information? (Check all that apply)	I read it		Checkbox, one-up vertical	Multi	Y
			I saved it for my records
			I shared it (or plan to share it) with my VA health care provider
			I shared it (or plan to share it) with my Non-VA health care provider
			I shared it (or plan to share it) with my spouse, child, or other family member
			I discarded it
			Other, please specify	C3
EDO07302	C3	What else did you do with the printed paper copy?			Text area, no char limit		Y
EDO07303	C4	What did you do with the Blue Button file containing your personal health information? (Check all that apply)	I saved it to my computer		Checkbox, one-up vertical	Multi	Y
			I stored the file on a CD, portable drive, or other media
			I uploaded the file to another website or software system
			I added the information to another personal health record
			I shared it (or plan to share it) with my VA health care provider
			I shared it (or plan to share it) with my Non-VA health care provider
			I shared it (or plan to share it) with my spouse, child, or other family member
			I deleted it
			I was not able to locate the file
			Nothing
			Other, please specify	C5
EDO07304	C5	What else did you do with the Blue Button file?			Text area, no char limit		Y
EDO07305	D	Did you make any changes to the VA Blue Button file such as adding, changing, or removing information?	Yes		Drop down, select one	Single	Y
			No
			Not sure
EDO07306	E	What did you find useful about your use of the VA Blue Button (Check all that apply)	Having my VA personal health information in one place		Checkbox, one-up vertical	Multi	Y
			Having an electronic file of my VA personal health information
			Being able to share a copy of my VA personal health information with someone else
			Being able to edit the copy of my personal health information
			Other, please specify	E2
			Did not find it useful
EDO07307	E2	What else did you find useful about the VA Blue Button?			Text area, no char limit		Y
EDO07308	F	What information in the VA Blue Button file was most useful? (Check all that apply	My self-entered information		Checkbox, one-up vertical	Multi	Y
			My HealtheVet Account Summary
			My VA Medication History (available to In-Person Authenticated veterans)
			My VA Wellness Reminders (available to In-Person Authenticated veterans)
			Other, please specify	F2
EDO07309	F2	What information was most useful?			Text area, no char limit		Y
EDO07310		What additional features would you find useful if added to the VA Blue Button? (Check all that apply)	Being able to include additional kinds of information as it becomes available in My HealtheVet, such as VA lab test results		Checkbox, one-up vertical	Multi	Y
			Being able to select a date range for the data included in my VA Blue Button download
			Being able to pick which portions of my personal health information are included in my VA Blue Button download
			Being able to transfer my personal health information to a non-VA personal health record or application
			Being able to access the information on other devices (for example a portable drive or mobile device)
			Being able to choose the format of the VA Blue Button file
			Other, please specify	A
			None
EDO07311	A	What other features would you find useful?			Text area, no char limit		Y
EDO07312		About how often do you plan to download your personal health information using the VA Blue Button?	One time only		Radio button, one-up vertical	Singly	Y
			About once a month
			About once every three months
			About once every six months
			About once a year
			Less frequently than once a year
			Only when I have a VA health care visit
			Other, please specify	A
			Not sure
			Never
EDO07313	A	How often do you plan to download your information?					Y
EDO07314		How can you see yourself using the VA Blue Button download in the future? (Check all that apply)	Save the information to another place (for example, by copying to a file on my computer)		Radio button, one-up vertical	Multi	Y
			Share the information with a family member or friend
			Share the information with my VA health care provider
			Share the information with my Non-VA health care provider
			Use the information with another program (for example, to check for drug interactions)
			Put the information into another Personal Health Record
			Put the information in another website (for example, to receive customized care recommendations or to apply other kinds of tools to my personal health information)
			I do not plan to use the VA Blue Button
			Not sure
EDO07315		Veterans who have completed In-Person Authentication (IPA) can download additional information using the VA Blue Button, including their VA Medication History and VA Wellness Reminders. Do you plan to complete In-Person Authentication in order to have access to this additional information?	Yes		Drop down, select one	Single	Y
			No, I am already In-Person Authenticated
			No
			Not sure
EDO03808		VA is interested in whether you would like to use My HealtheVet to share your information with others involved in your health care (for example, medications, lab results, appointments).<p>If you could allow one or more people (your "designated persons") to see some or all of your information in your My HealtheVet Personal Health Record, which of the following people might you choose? (Check all that apply)		B, C, D	Checkbox, one-up vertical	Multi	Y	Who Allowed
			Child	B, E, F, G
			Other family member	B, E, F, G
			Caregiver not related to me	B, H, I
			Friend or neighbor	B, J, K
			VA health care provider	B, L
			Non-VA health care provider	B, M
			Other, please specify	B, A
			Not sure	B
			None. I don't want to let other people view my health information.	B
EDO03809	A	What other person would you like to have access to your information?			Text area, no char limit			OE_Other Allowed
EDO03810	B	Please share your thoughts or concerns about allowing others to see your My HealtheVet information			Text area, no char limit			OE_Comment on Allow
EDO03811	C	Which parts, if any, of the My HealtheVet website would you want your spouse/partner to be able to see? (check all that apply)	Information about my scheduled VA appointments		Checkbox, one-up vertical			Spouse/Partner See
			My medication list
			Results from my laboratory tests and other tests
			Wellness Reminders about tests or care that I need (such as blood pressure check, vaccines, or cancer screen)
			Information that I've entered about my health (such as blood sugar, blood pressure, or weight)
			Information about my doctor(s)
			My secure messages (secure electronic messages sent to or received from my VA health care team through My HealtheVet Secure Messaging)
			Other, please specify	CC
			All of my information
			None
EDO03812	CC	What other information would you like your spouse/partner to be able to see?			Text area, no char limit			OE_Spouse/Partner See
EDO03813	D	Which of the following, if any, would you want your spouse/partner to be able to do on your behalf? (check all that apply)	Enter personal information (such as contact information, emergency contacts)		Checkbox, one-up vertical			Spouse Partner Do
			Enter information about my health (such as blood pressure, weight, medication list, allergy list)
			Refill prescriptions for me
			Schedule or manage my VA appointments
			Communicate electronically with my VA health care team through My HealtheVet Secure Messaging
			Save information from my personal health record to some place outside of My HealtheVet (for example another program or non-VA personal health record)
			Other, please specify	DD
			None
EDO03814	DD	What else would you like your spouse/partner to do on your behalf?			Text area, no char limit			OE_Spouse Partner Do
EDO03815	E	Which parts, if any, of the My HealtheVet website would you want your designated child or other family member to be able to see? (check all that apply)	Information about my scheduled VA appointments		Checkbox, one-up vertical	Multi	Y	Family Member See
			My medication list
			Results from my laboratory tests and other tests
			Wellness Reminders about tests or care that I need (such as blood pressure check, vaccines, or cancer screen)
			Information that I've entered about my health (such as blood sugar, blood pressure, or weight)
			Information about my doctor(s)
			My secure messages (secure electronic messages sent to or received from my VA health care team through My HealtheVet Secure Messaging)
			Other, please specify	EE
			All of my information
			None
EDO03816	EE	What other information would you like your child or family member to be able to see?			Text area, no char limit			OE_Family Member See
EDO03817	F	Which of the following, if any, would you want your designated child or other family member to be able to do on your behalf? (check all that apply)	Enter personal information (such as contact information, emergency contacts)		Checkbox, one-up vertical	Multi		Family Member Do
			Enter information about my health (such as blood pressure, weight, medication list, allergy list)
			Refill prescriptions for me
			Schedule or manage my VA appointments
			Communicate electronically with my VA health care team through My HealtheVet Secure Messaging
			Save information from my personal health record to some place outside of My HealtheVet (for example another program or non-VA personal health record)
			Other, please specify	FF
			None
EDO03818	FF	What else would you like your child or other family member to do on your behalf?			Text area, no char limit			OE_Family Member Do
EDO03819	G	Does the family member that you would most likely designate to have access to information in your My HealtheVet Personal Health Record live with you?	Yes, they live with me		Radio button, one-up vertical	Single		Family Member Live
			No, they do not live with me, but they visit me regularly
			No, they do not live with me, but we are in frequent contact by phone or email
			No, they do not live with me, and we are less frequently in contact
EDO03820	H	Which parts, if any, of the My HealtheVet website would you want your designated caregiver to be able to see? (check all that apply)	Information about my scheduled VA appointments		Checkbox, one-up vertical	Multi		Caregiver See
			My medication list
			Results from my laboratory tests and other tests
			Wellness Reminders about tests or care that I need (such as blood pressure check, vaccines, or cancer screen)
			Information that I've entered about my health (such as blood sugar, blood pressure, or weight)
			Information about my doctor(s)
			My secure messages (secure electronic messages sent to or received from my VA health care team through My HealtheVet Secure Messaging)
			Other, please specify	HH
			All of my information
			None
EDO03821	HH	What other information would you like your caregiver to be able to see?			Text area, no char limit			OE_Caregiver See
EDO03822	I	Which of the following, if any, would you want your designated caregiver to be able to do on your behalf? (check all that apply)	Enter personal information (such as contact information, emergency contacts)		Checkbox, one-up vertical	Multi		Caregiver Do
			Enter information about my health (such as blood pressure, weight, medication list, allergy list)
			Refill prescriptions for me
			Schedule or manage my VA appointments
			Communicate electronically with my VA health care team through My HealtheVet Secure Messaging
			Save information from my personal health record to some place outside of My HealtheVet (for example another program or non-VA personal health record)
			Other, please specify	II
			None
EDO03823	II	What else would you like your caregiver to do on your behalf?			Text area, no char limit			OE_Caregiver Do
EDO03824	J	Which parts, if any, of the My HealtheVet website would you want your designated friend or neighbor to be able to see? (check all that apply)	Information about my scheduled VA appointments		Checkbox, one-up vertical	Multi		Friend See
			My medication list
			Results from my laboratory tests and other tests
			Wellness Reminders about tests or care that I need (such as blood pressure check, vaccines, or cancer screen)
			Information that I've entered about my health (such as blood sugar, blood pressure, or weight)
			Information about my doctor(s)
			My secure messages (secure electronic messages sent to or received from my VA health care team through My HealtheVet Secure Messaging)
			Other, please specify	JJ
			All of my information
			None
EDO03825	JJ	What other information would you like your friend or neighbor to be able to see?			Text area, no char limit			OE_Friend See
EDO03826	K	Which of the following, if any, would you want your designated friend or neighbor to be able to do on your behalf? (check all that apply)	Enter personal information (such as contact information, emergency contacts)		Checkbox, one-up vertical	Multi		Friend Do
			Enter information about my health (such as blood pressure, weight, medication list, allergy list)
			Refill prescriptions for me
			Schedule or manage my VA appointments
			Communicate electronically with my VA health care team through My HealtheVet Secure Messaging
			Save information from my personal health record to some place outside of My HealtheVet (for example another program or non-VA personal health record)
			Other, please specify	KK
			None
EDO03827	KK	What else would you like your friend or neighbor to do on your behalf?			Text area, no char limit			OE_Friend Do
EDO03828	L	Which parts, if any, of the My HealtheVet website would you want your designated VA health care provider to be able to see (check all that apply):	Information about my scheduled VA appointments		Checkbox, one-up vertical	Multi		VA HCP See
			My medication list
			Results from my laboratory tests and other tests
			Information that I've entered about my health (such as blood sugar, blood pressure, or weight)
			Information about my doctor(s)
			Other, please specify	LL
			All of my information
			None
EDO03829	LL	What other information would you like your VA health care provider to be able to see?			Text area, no char limit			OE_VA HCP See
EDO03830	M	Which parts, if any, of the My HealtheVet website would you want your designated Non-VA health care provider to be able to see (check all that apply):	Information about my scheduled VA appointments		Checkbox, one-up vertical	Multi	Y	Non-VA HCP See
			My medication list
			Results from my laboratory tests and other tests
			Wellness Reminders about tests or care that I need (such as blood pressure check, vaccines, or cancer screen)
			Information that I've entered about my health (such as blood sugar, blood pressure, or weight)
			Information about my doctor(s)
			My secure messages (secure electronic messages sent to or received from my VA health care team through My HealtheVet Secure Messaging)
			Other, please specify	MM
			All of my information
			None
EDO03831	MM	What other information would you like your non-VA health care provider to be able to see?			Text area, no char limit			OE_Non-VA HCP See
EDO03832		At your last VA health care visit, who did you discuss your medications with? (check all that apply)	Health care provider (doctor, physicians assistant, nurse practitioner)		Checkbox, one-up vertical	Multi	Y	Who Discuss Meds
			Nurse
			Pharmacist
			Medical assistant or health technician
			Other staff member, please specify	A
			No one. I did not discuss my medications
			I don't take any medications
			I do not remember
EDO03833	A	What other staff member did you discuss medications with?						OE_Who Discuss Meds
EDO03834		If you had a choice, which member of the health care team would you most like to talk with about your medications at your next VA health care visit? (check all that apply)	Health care provider (doctor, physicians assistant, nurse practitioner)		Checkbox, one-up vertical	Multi	Y	Discuss Meds Choice
			Nurse
			Pharmacist
			Medical assistant or health technician
			Other staff member, please specify	A
			No one
			I don't take any medications
			Not sure
EDO03835	A	What other staff member would you like to talk with about medications?			Text area, no char limit			OE_Discuss Meds Choice
EDO03836		Do you use the My HealtheVet Pharmacy Self-Entered Medications + Supplements feature to keep track of any changes to your prescription medications, over-the-counter medications, herbals and/or supplements?	Yes	A, B, C	Radio button, one-up vertical	Single	Y	Use Self Entered Meds
			No
			Not sure
EDO03837	A	Which kinds of medications do you keep track of in My HealtheVet? (check all that apply)	Prescription medications from my home VA healthcare provider filled at the VA pharmacy		Checkbox, one-up vertical	Multi	Y	Med type tracked
			Prescription medications from my home VA healthcare provider filled at non VA pharmacies
			Prescription medications from VA healthcare providers at VA facilities other than my home VA facility
			Prescription medications from my non-VA healthcare provider(s)
			Over-the-counter medications
			Herbals and/or supplements
			Other, please specify	AA
EDO03838	AA	What other medications do you keep track of in My HealtheVet?			Text area, no char limit			OE_Med type tracked
EDO03839	B	In the last 12 months, did you share your My HealtheVet My Complete Medications List with any of your VA health care providers?	Yes		Radio button, one-up vertical	Single	Y	Share med list w/ VA HCP
			No
			Not sure
EDO03840	C	In the last 12 months, did you share your My HealtheVet My Complete Medications List with any of your Non-VA health care providers?	Yes		Radio button, one-up vertical	Single	Y	Share med list w/Non-VA HCP
			No
			Not sure
RJB00029		My use of the My HealtheVet personal health record has improved my ability to manage my health.	Strongly agree		Drop down, select one	Single	Y
			Agree
			Not sure
			Disagree
			Strongly disagree
			Not applicable
ALM0173		What is the main improvement that you would suggest for the My HealtheVet web site?			Open-ended	Single	N
KFB04531		The My HealtheVet website provides articles on topics of interest to Veterans. What topics are you most interested in for upcoming articles?			Text area, no char limit	Single	N
AED02714		What is your age range?	Under 20		Dropdown (Select-one)	Single	N
			20-24
			25-29
			30-34
			35-39
			40-44
			45-49
			50-54
			55-59
			60-64
			65-69
			70-74
			75-79
			80-84
			85 or older
JIC00267		What is your gender?	Male		Dropdown (Select-one)	Single	N
			Female
JIC00178		In general, how would you rate your overall health?	Excellent		Dropdown (Select-one)	Single	Y
			Very Good
			Good
			Fair
			Poor
AED06379		Have you completed this survey within the past 3 months?	Yes		Radio button, one-up vertical
			No			Single	N
			Don't recall

---

Sheet 21: Custom Qsts (7-8-10)

Model Instance Name: VA - My HealtheVet			red & strike-through: DELETE
MID:	NJxFtMU9UosBkJZRd48x9Q==		underlined & italicized: RE-ORDER
			pink: ADDITION
Date:	6/23/2009		blue + -->: REWORDING
			violet (bold): SKIP-LOGIC
MID: CUSTOM QUESTION LIST
QID	Skip Logic Label	Question Text	Answer Choices (limited to 50 characters)	Skip to	Type (select from list)	Single or Multi	Required Y/N	Question Label
ALM0169		How frequently do you visit the My HealtheVet web site?	First time		Dropdown (Select-one)	Single	Y
			Daily
			More than once a day
			About once a week
			About once a month
			About every 6 months
			Less than every 6 months
ALM0170		Which of the following best describes you?	Active duty		Checkbox, one-up vertical	Multi	Y
			Veteran
			Family member of a veteran
			Veteran service organization
			News media
			General public
			VA employee
			Federal government employee
			State/local government employee
			Other role
RJB00048		Please indicate your military period(s) of service:	Global War on Terror (OEF/OIF)		Check-boxes	Multi	N
			Desert Shield/Desert Storm
			Vietnam War
			Korean War
			World War II
			Peacetime Service
			Other
			Not Applicable
RJB00022		What were you trying to accomplish today in My HealtheVet? (please select all that apply)	Enter/keep track of personal information (My Caregivers, etc.)		Check-boxes	Multi	Y
			Enter/keep track of personal health care information (blood pressure, blood sugar, etc.)
			Look up information about a medication
			Request a prescription refill
			Access prescription history from my VA medical record
			Find a VA health care facility
			Research a health condition
			Find information about VA Benefits
			Other (please specify)	A
RJB00022other	A	Other - trying to accomplish			Text field, <100 char	Single	N
ALM0172		Did you accomplish what you wanted to in My HealtheVet?	Yes		Dropdown (Select-one)	Single	Y
			No
			Partially
			Not finished yet
RJB00026		Are you a registered user on the MyHealtheVet web site?	Yes		Dropdown (Select-one)	Single	Y
			No
			Not sure
RJB00027		Have you visited your VA Facility in person to show your ID and be "in-person authenticated" (IPA) for My HealtheVet?	Yes		Dropdown (Select-one)	Single	Y
			No
			Not sure
			Not applicable
EDO03808		VA is interested in whether you would like to use My HealtheVet to share your information with others involved in your health care (for example, medications, lab results, appointments).<p>If you could allow one or more people (your "designated persons") to see some or all of your information in your My HealtheVet Personal Health Record, which of the following people might you choose? (Check all that apply)	Spouse/Partner	B, C, D	Checkbox, one-up vertical	Multi	Y	Who Allowed
			Child	B, E, F, G
			Other family member	B, E, F, G
			Caregiver not related to me	B, H, I
			Friend or neighbor	B, J, K
			VA health care provider	B, L
			Non-VA health care provider	B, M
			Other, please specify	B, A
			Not sure	B
			None. I don't want to let other people view my health information.	B
EDO03809	A	What other person would you like to have access to your information?			Text area, no char limit			OE_Other Allowed
EDO03810	B	Please share your thoughts or concerns about allowing others to see your My HealtheVet information			Text area, no char limit			OE_Comment on Allow
EDO03811	C	Which parts, if any, of the My HealtheVet website would you want your spouse/partner to be able to see? (check all that apply)	Information about my scheduled VA appointments		Checkbox, one-up vertical			Spouse/Partner See
			My medication list
			Results from my laboratory tests and other tests
			Wellness Reminders about tests or care that I need (such as blood pressure check, vaccines, or cancer screen)
			Information that I've entered about my health (such as blood sugar, blood pressure, or weight)
			Information about my doctor(s)
			My secure messages (secure electronic messages sent to or received from my VA health care team through My HealtheVet Secure Messaging)
			Other, please specify	CC
			All of my information
			None
EDO03812	CC	What other information would you like your spouse/partner to be able to see?			Text area, no char limit			OE_Spouse/Partner See
EDO03813	D	Which of the following, if any, would you want your spouse/partner to be able to do on your behalf? (check all that apply)	Enter personal information (such as contact information, emergency contacts)		Checkbox, one-up vertical			Spouse Partner Do
			Enter information about my health (such as blood pressure, weight, medication list, allergy list)
			Refill prescriptions for me
			Schedule or manage my VA appointments
			Communicate electronically with my VA health care team through My HealtheVet Secure Messaging
			Save information from my personal health record to some place outside of My HealtheVet (for example another program or non-VA personal health record)
			Other, please specify	DD
			None
EDO03814	DD	What else would you like your spouse/partner to do on your behalf?			Text area, no char limit			OE_Spouse Partner Do
EDO03815	E	Which parts, if any, of the My HealtheVet website would you want your designated child or other family member to be able to see? (check all that apply)	Information about my scheduled VA appointments		Checkbox, one-up vertical	Multi	Y	Family Member See
			My medication list
			Results from my laboratory tests and other tests
			Wellness Reminders about tests or care that I need (such as blood pressure check, vaccines, or cancer screen)
			Information that I've entered about my health (such as blood sugar, blood pressure, or weight)
			Information about my doctor(s)
			My secure messages (secure electronic messages sent to or received from my VA health care team through My HealtheVet Secure Messaging)
			Other, please specify	EE
			All of my information
			None
EDO03816	EE	What other information would you like your child or family member to be able to see?			Text area, no char limit			OE_Family Member See
EDO03817	F	Which of the following, if any, would you want your designated child or other family member to be able to do on your behalf? (check all that apply)	Enter personal information (such as contact information, emergency contacts)		Checkbox, one-up vertical	Multi		Family Member Do
			Enter information about my health (such as blood pressure, weight, medication list, allergy list)
			Refill prescriptions for me
			Schedule or manage my VA appointments
			Communicate electronically with my VA health care team through My HealtheVet Secure Messaging
			Save information from my personal health record to some place outside of My HealtheVet (for example another program or non-VA personal health record)
			Other, please specify	FF
			None
EDO03818	FF	What else would you like your child or other family member to do on your behalf?			Text area, no char limit			OE_Family Member Do
EDO03819	G	Does the family member that you would most likely designate to have access to information in your My HealtheVet Personal Health Record live with you?	Yes, they live with me		Radio button, one-up vertical	Single		Family Member Live
			No, they do not live with me, but they visit me regularly
			No, they do not live with me, but we are in frequent contact by phone or email
			No, they do not live with me, and we are less frequently in contact
EDO03820	H	Which parts, if any, of the My HealtheVet website would you want your designated caregiver to be able to see? (check all that apply)	Information about my scheduled VA appointments		Checkbox, one-up vertical	Multi		Caregiver See
			My medication list
			Results from my laboratory tests and other tests
			Wellness Reminders about tests or care that I need (such as blood pressure check, vaccines, or cancer screen)
			Information that I've entered about my health (such as blood sugar, blood pressure, or weight)
			Information about my doctor(s)
			My secure messages (secure electronic messages sent to or received from my VA health care team through My HealtheVet Secure Messaging)
			Other, please specify	HH
			All of my information
			None
EDO03821	HH	What other information would you like your caregiver to be able to see?			Text area, no char limit			OE_Caregiver See
EDO03822	I	Which of the following, if any, would you want your designated caregiver to be able to do on your behalf? (check all that apply)	Enter personal information (such as contact information, emergency contacts)		Checkbox, one-up vertical	Multi		Caregiver Do
			Enter information about my health (such as blood pressure, weight, medication list, allergy list)
			Refill prescriptions for me
			Schedule or manage my VA appointments
			Communicate electronically with my VA health care team through My HealtheVet Secure Messaging
			Save information from my personal health record to some place outside of My HealtheVet (for example another program or non-VA personal health record)
			Other, please specify	II
			None
EDO03823	II	What else would you like your caregiver to do on your behalf?			Text area, no char limit			OE_Caregiver Do
EDO03824	J	Which parts, if any, of the My HealtheVet website would you want your designated friend or neighbor to be able to see? (check all that apply)	Information about my scheduled VA appointments		Checkbox, one-up vertical	Multi		Friend See
			My medication list
			Results from my laboratory tests and other tests
			Wellness Reminders about tests or care that I need (such as blood pressure check, vaccines, or cancer screen)
			Information that I've entered about my health (such as blood sugar, blood pressure, or weight)
			Information about my doctor(s)
			My secure messages (secure electronic messages sent to or received from my VA health care team through My HealtheVet Secure Messaging)
			Other, please specify	JJ
			All of my information
			None
EDO03825	JJ	What other information would you like your friend or neighbor to be able to see?			Text area, no char limit			OE_Friend See
EDO03826	K	Which of the following, if any, would you want your designated friend or neighbor to be able to do on your behalf? (check all that apply)	Enter personal information (such as contact information, emergency contacts)		Checkbox, one-up vertical	Multi		Friend Do
			Enter information about my health (such as blood pressure, weight, medication list, allergy list)
			Refill prescriptions for me
			Schedule or manage my VA appointments
			Communicate electronically with my VA health care team through My HealtheVet Secure Messaging
			Save information from my personal health record to some place outside of My HealtheVet (for example another program or non-VA personal health record)
			Other, please specify	KK
			None
EDO03827	KK	What else would you like your friend or neighbor to do on your behalf?			Text area, no char limit			OE_Friend Do
EDO03828	L	Which parts, if any, of the My HealtheVet website would you want your designated VA health care provider to be able to see (check all that apply):	Information about my scheduled VA appointments		Checkbox, one-up vertical	Multi		VA HCP See
			My medication list
			Results from my laboratory tests and other tests
			Information that I've entered about my health (such as blood sugar, blood pressure, or weight)
			Information about my doctor(s)
			Other, please specify	LL
			All of my information
			None
EDO03829	LL	What other information would you like your VA health care provider to be able to see?			Text area, no char limit			OE_VA HCP See
EDO03830	M	Which parts, if any, of the My HealtheVet website would you want your designated Non-VA health care provider to be able to see (check all that apply):	Information about my scheduled VA appointments		Checkbox, one-up vertical	Multi	Y	Non-VA HCP See
			My medication list
			Results from my laboratory tests and other tests
			Wellness Reminders about tests or care that I need (such as blood pressure check, vaccines, or cancer screen)
			Information that I've entered about my health (such as blood sugar, blood pressure, or weight)
			Information about my doctor(s)
			My secure messages (secure electronic messages sent to or received from my VA health care team through My HealtheVet Secure Messaging)
			Other, please specify	MM
			All of my information
			None
EDO03831	MM	What other information would you like your non-VA health care provider to be able to see?			Text area, no char limit			OE_Non-VA HCP See
EDO03832		At your last VA health care visit, who did you discuss your medications with? (check all that apply)	Health care provider (doctor, physicians assistant, nurse practitioner)		Checkbox, one-up vertical	Multi	Y	Who Discuss Meds
			Nurse
			Pharmacist
			Medical assistant or health technician
			Other staff member, please specify	A
			No one. I did not discuss my medications
			I don't take any medications
			I do not remember
EDO03833	A	What other staff member did you discuss medications with?						OE_Who Discuss Meds
EDO03834		If you had a choice, which member of the health care team would you most like to talk with about your medications at your next VA health care visit? (check all that apply)	Health care provider (doctor, physicians assistant, nurse practitioner)		Checkbox, one-up vertical	Multi	Y	Discuss Meds Choice
			Nurse
			Pharmacist
			Medical assistant or health technician
			Other staff member, please specify	A
			No one
			I don't take any medications
			Not sure
EDO03835	A	What other staff member would you like to talk with about medications?			Text area, no char limit			OE_Discuss Meds Choice
EDO03836		Do you use the My HealtheVet Pharmacy Self-Entered Medications + Supplements feature to keep track of any changes to your prescription medications, over-the-counter medications, herbals and/or supplements?	Yes	A, B, C	Radio button, one-up vertical	Single	Y	Use Self Entered Meds
			No
			Not sure
EDO03837	A	Which kinds of medications do you keep track of in My HealtheVet? (check all that apply)	Prescription medications from my home VA healthcare provider filled at the VA pharmacy		Checkbox, one-up vertical	Multi	Y	Med type tracked
			Prescription medications from my home VA healthcare provider filled at non VA pharmacies
			Prescription medications from VA healthcare providers at VA facilities other than my home VA facility
			Prescription medications from my non-VA healthcare provider(s)
			Over-the-counter medications
			Herbals and/or supplements
			Other, please specify	AA
EDO03838	AA	What other medications do you keep track of in My HealtheVet?			Text area, no char limit			OE_Med type tracked
EDO03839	B	In the last 12 months, did you share your My HealtheVet My Complete Medications List with any of your VA health care providers?	Yes		Radio button, one-up vertical	Single	Y	Share med list w/ VA HCP
			No
			Not sure
EDO03840	C	In the last 12 months, did you share your My HealtheVet My Complete Medications List with any of your Non-VA health care providers?	Yes		Radio button, one-up vertical	Single	Y	Share med list w/Non-VA HCP
			No
			Not sure
AED11236		Have you ever printed out any information from My HealtheVet?	Yes	A	Radio button, one-up vertical	Single	Y	Print Info
			No
AED11237	A	I have printed the following from My HealtheVet: (Check all that apply)	My medication list		Checkbox, one-up vertical	Multi	Y	Printed Docs
			Information about myself that I collected at home (such as blood sugar, blood pressure, or weight)
			Information I entered in my Food or Activity Journals
			My health calendar
			Wellness Reminders
			Information about health (such as an article or information from the medical library)
			Information about VA benefits
			Other, please specify	B
AED11238	B	What other information have you printed?			Text area, no char limit		N	Other Printed Docs
AED11239		Have you ever saved any information from My HealtheVet to your computer?	Yes	A	Radio button, one-up vertical	Singly	Y	Saved Info
			No
AED11240	A	I have saved the following from My HealtheVet to my computer: (Check all that apply)	My medication list		Checkbox, one-up vertical	Multi	Y	Docs Saved
			Information about myself that I collected at home (such as blood sugar, blood pressure, or weight)
			Information I entered in my Food or Activity Journals
			My health calendar
			Wellness Reminders
			Information about health (such as an article or information from the medical library)
			Information about VA benefits
			Other, please specify	B
AED11241	B	What other information have you saved to your computer?						Other Docs Saved
AED11242		Have you ever sent information from My HealtheVet to another person?	Yes	A	Radio button, one-up vertical	Single	Y	Sent Info
			No
AED11243	A	I have sent the following information from My HealtheVet to another person: (Check all that apply)	My medication list		Checkbox, one-up vertical	Multi	Y	Docs Sent
			Information about myself that I collected at home (such as blood sugar, blood pressure, or weight)
			Information I entered in my Food or Activity Journals
			My health calendar
			Wellness Reminders
			Information about health (such as an article or information from the medical library)
			Information about VA benefits
			Other, please specify	B
AED11244	B	What other information did you send to another person?			Text area, no char limit			Other Docs Sent
AED11245		Would you save information from your Personal Health Record to some place outside of My HealtheVet If you could?	Yes	A	Radio button, one-up vertical	Single	Y	Save to Location
			No
			Not sure	A
			I would not find this useful
AED11246	A	I would: (check all that apply):	Save the information to another place (for example, by copying to a file on my computer)		Checkbox, one-up vertical	Multi	Y	Locations Saved
			Give the electronic information to my non-VA provider
			Share the information with a family member or friend
			Put the information into another Personal Health Record
			Use the information with another program (for example, to check for drug interactions)
			Put the information in another website (for example, to receive customized care recommendations or to use other kinds of tools)
			Other, please specify	B
AED11247	B	Where else would you like to save information?						Other Locations Saved
RJB00029		My use of the My HealtheVet personal health record has improved my ability to manage my health.	Strongly agree		Drop down, select one	Single	Y
			Agree
			Not sure
			Disagree
			Strongly disagree
			Not applicable
ALM0173		What is the main improvement that you would suggest for the My HealtheVet web site?			Open-ended	Single	N
KFB04531		The My HealtheVet website provides articles on topics of interest to Veterans. What topics are you most interested in for upcoming articles?			Text area, no char limit	Single	N
AED02714		What is your age range?	Under 20		Dropdown (Select-one)	Single	N
			20-24
			25-29
			30-34
			35-39
			40-44
			45-49
			50-54
			55-59
			60-64
			65-69
			70-74
			75-79
			80-84
			85 or older
JIC00267		What is your gender?	Male		Dropdown (Select-one)	Single	N
			Female
JIC00178		In general, how would you rate your overall health?	Excellent		Dropdown (Select-one)	Single	Y
			Very Good
			Good
			Fair
			Poor
AED06379		Have you completed this survey within the past 3 months?	Yes		Radio button, one-up vertical
			No			Single	N
			Don't recall

---

Sheet 22: Custom Qsts (2-24-10)

Model Instance Name: VA - My HealtheVet			red & strike-through: DELETE
MID:	NJxFtMU9UosBkJZRd48x9Q==		underlined & italicized: RE-ORDER
			pink: ADDITION
Date:	6/23/2009		blue + -->: REWORDING
			violet (bold): SKIP-LOGIC
MID: CUSTOM QUESTION LIST
QID	Skip Logic Label	Question Text	Answer Choices (limited to 50 characters)	Skip to	Type (select from list)	Single or Multi	Required Y/N	Question Label
ALM0169		How frequently do you visit the My HealtheVet web site?	First time		Dropdown (Select-one)	Single	Y
			Daily
			More than once a day
			About once a week
			About once a month
			About every 6 months
			Less than every 6 months
ALM0170		Which of the following best describes you?	Active duty		Checkbox, one-up vertical	Multi	Y
			Veteran
			Family member of a veteran
			Veteran service organization
			News media
			General public
			VA employee
			Federal government employee
			State/local government employee
			Other role
RJB00048		Please indicate your military period(s) of service:	Global War on Terror (OEF/OIF)		Check-boxes	Multi	N
			Desert Shield/Desert Storm
			Vietnam War
			Korean War
			World War II
			Peacetime Service
			Other
			Not Applicable
RJB00022		What were you trying to accomplish today in My HealtheVet? (please select all that apply)	Enter/keep track of personal information (My Caregivers, etc.)		Check-boxes	Multi	Y
			Enter/keep track of personal health care information (blood pressure, blood sugar, etc.)
			Look up information about a medication
			Request a prescription refill
			Access prescription history from my VA medical record
			Find a VA health care facility
			Research a health condition
			Find information about VA Benefits
			Other (please specify)	A
RJB00022other	A	Other - trying to accomplish			Text field, <100 char	Single	N
ALM0172		Did you accomplish what you wanted to in My HealtheVet?	Yes		Dropdown (Select-one)	Single	Y
			No
			Partially
			Not finished yet
RJB00026		Are you a registered user on the MyHealtheVet web site?	Yes		Dropdown (Select-one)	Single	Y
			No
			Not sure
RJB00027		Have you visited your VA Facility in person to show your ID and be "in-person authenticated" (IPA) for My HealtheVet?	Yes		Dropdown (Select-one)	Single	Y
			No
			Not sure
			Not applicable
		Have you ever printed out any information from My HealtheVet?	Yes	A	Radio button, one-up vertical	Single	Y
			No
	A	I have printed the following from My HealtheVet: (Check all that apply)	My medication list		Checkbox, one-up vertical	Multi	Y
			Information about myself that I collected at home (such as blood sugar, blood pressure, or weight)
			Information I entered in my Food or Activity Journals
			My health calendar
			Wellness Reminders
			Information about health (such as an article or information from the medical library)
			Information about VA benefits
			Other, please specify	B
	B	What other information have you printed?			Text area, no char limit		N
		Have you ever saved any information from My HealtheVet to your computer?	Yes	A	Radio button, one-up vertical	Singly	Y
			No
	A	I have saved the following from My HealtheVet to my computer: (Check all that apply)	My medication list		Checkbox, one-up vertical	Multi	Y
			Information about myself that I collected at home (such as blood sugar, blood pressure, or weight)
			Information I entered in my Food or Activity Journals
			My health calendar
			Wellness Reminders
			Information about health (such as an article or information from the medical library)
			Information about VA benefits
			Other, please specify	B
	B	What other information have you saved to your computer?
		Have you ever sent information from My HealtheVet to another person?	Yes	A	Radio button, one-up vertical	Single	Y
			No
	A	I have sent the following information from My HealtheVet to another person: (Check all that apply)	My medication list		Checkbox, one-up vertical	Multi	Y
			Information about myself that I collected at home (such as blood sugar, blood pressure, or weight)
			Information I entered in my Food or Activity Journals
			My health calendar
			Wellness Reminders
			Information about health (such as an article or information from the medical library)
			Information about VA benefits
			Other, please specify	B
	B	What other information did you send to another person?			Text area, no char limit
		Would you save information from your Personal Health Record to some place outside of My HealtheVet If you could?	Yes	A	Radio button, one-up vertical	Single	Y
			No
			Not sure	A
			I would not find this useful
	A	I would: (check all that apply):	Save the information to another place (for example, by copying to a file on my computer)		Checkbox, one-up vertical	Multi	Y
			Give the electronic information to my non-VA provider
			Share the information with a family member or friend
			Put the information into another Personal Health Record
			Use the information with another program (for example, to check for drug interactions)
			Put the information in another website (for example, to receive customized care recommendations or to use other kinds of tools)
			Other, please specify	B
	B	Where else would you like to save information?
RJB00029		My use of the My HealtheVet personal health record has improved my ability to manage my health.	Strongly agree		Drop down, select one	Single	Y
			Agree
			Not sure
			Disagree
			Strongly disagree
			Not applicable
ALM0173		What is the main improvement that you would suggest for the My HealtheVet web site?			Open-ended	Single	N
KFB04531		The My HealtheVet website provides articles on topics of interest to Veterans. What topics are you most interested in for upcoming articles?			Text area, no char limit	Single	N
AED02714		What is your age range?	Under 20		Dropdown (Select-one)	Single	N
			20-24
			25-29
			30-34
			35-39
			40-44
			45-49
			50-54
			55-59
			60-64
			65-69
			70-74
			75-79
			80-84
			85 or older
JIC00267		What is your gender?	Male		Dropdown (Select-one)	Single	N
			Female
JIC00178		In general, how would you rate your overall health?	Excellent		Dropdown (Select-one)	Single	Y
			Very Good
			Good
			Fair
			Poor
AED06379		Have you completed this survey within the past 3 months?	Yes		Radio button, one-up vertical
			No			Single	N
			Don't recall

---

Sheet 23: Custom Qsts (11-06-09)

Model Instance Name: VA - My HealtheVet			red & strike-through: DELETE
MID:	NJxFtMU9UosBkJZRd48x9Q==		underlined & italicized: RE-ORDER
			pink: ADDITION
Date:	6/23/2009		blue + -->: REWORDING
			violet (bold): SKIP-LOGIC
MID: CUSTOM QUESTION LIST
QID	Skip Logic Label	Question Text	Answer Choices (limited to 50 characters)	Skip to	Type (select from list)	Single or Multi	Required Y/N	Question Label
ALM0169		How frequently do you visit the My HealtheVet web site?	First time		Dropdown (Select-one)	Single	Y
			Daily
			More than once a day
			About once a week
			About once a month
			About every 6 months
			Less than every 6 months
ALM0170		Which of the following best describes you?	Active duty		Checkbox, one-up vertical	Multi	Y
			Veteran
			Family member of a veteran
			Veteran service organization
			News media
			General public
			VA employee
			Federal government employee
			State/local government employee
			Other role
RJB00048		Please indicate your military period(s) of service:	Global War on Terror (OEF/OIF)		Check-boxes	Multi	N
			Desert Shield/Desert Storm
			Vietnam War
			Korean War
			World War II
			Peacetime Service
			Other
			Not Applicable
RJB00022		What were you trying to accomplish today in My HealtheVet? (please select all that apply)	Enter/keep track of personal information (My Caregivers, etc.)		Check-boxes	Multi	Y
			Enter/keep track of personal health care information (blood pressure, blood sugar, etc.)
			Look up information about a medication
			Request a prescription refill
			Access prescription history from my VA medical record
			Find a VA health care facility
			Research a health condition
			Find information about VA Benefits
			Other (please specify)	A
RJB00022other	A	Other - trying to accomplish			Text field, <100 char	Single	N
ALM0172		Did you accomplish what you wanted to in My HealtheVet?	Yes		Dropdown (Select-one)	Single	Y
			No
			Partially
			Not finished yet
RJB00026		Are you a registered user on the MyHealtheVet web site?	Yes		Dropdown (Select-one)	Single	Y
			No
			Not sure
RJB00027		Have you visited your VA Facility in person to show your ID and be "in-person authenticated" (IPA) for My HealtheVet?	Yes		Dropdown (Select-one)	Single	Y
			No
			Not sure
			Not applicable
RJB00029		My use of the My HealtheVet personal health record has improved my ability to manage my health.	Strongly agree		Drop down, select one	Single	Y
			Agree
			Not sure
			Disagree
			Strongly disagree
			Not applicable
ALM0173		What is the main improvement that you would suggest for the My HealtheVet web site?			Open-ended	Single	N
AED08728		Have you ever visited the Healthy Living Spirituality Center?	Yes	A, B	Dropdown (Select-one)	Single	Y	Spirituality Center
			No	C
			Not sure
AED08729	A	How helpful did you find it?	Very helpful		Drop down, select one	Single	Y	SC_Helpful
			Somewhat helpful
			Undecided
			Not very helpful
			Not helpful at all
AED08730	B	Which parts were most useful to you? (Check all that apply)	Get Ready: Benefits of change, how to start healthy living, and special situations		Checkbox, one-up vertical	Multi	Y	SC_Useful
			Self Management: Understand and track your progress through use of various tools
			Support and Encouragement: How a VA chaplain, local clergy, family and friends can support healthy living
			Caregiver Information: Caregiver resources and when to get additional help
			Related Topics: Body, mind and spirit connections
			None of the above
AED08731	C	Why did you not visit the Healthy Living Spirtuality Center?	Not interested		Drop down, select one	Single	Y	SC_DidNotVisit
			Did not know about it
			Could not find it
AED08732		What spirituality resources would be of value to you as part of the Healthy Living Center? (check all that apply)	Article on a given topic	A	Checkbox, two-up vertical	Multi	Y	Spirituality Resources
			Devotions or meditations
			Sample prayers
			Other, please specify	B
AED08733	A	What article topic would be of value to you?			Text area, no char limit			SR_Articles
AED08734	B	What other spirituality resource would be of value to you?			Text area, no char limit			SR_OtherResource
KFB04531		The My HealtheVet website provides articles on topics of interest to Veterans. What topics are you most interested in for upcoming articles?			Text area, no char limit	Single	N
AED02714		What is your age range?	Under 20		Dropdown (Select-one)	Single	N
			20-24
			25-29
			30-34
			35-39
			40-44
			45-49
			50-54
			55-59
			60-64
			65-69
			70-74
			75-79
			80-84
			85 or older
JIC00267		What is your gender?	Male		Dropdown (Select-one)	Single	N
			Female
JIC00178		In general, how would you rate your overall health?	Excellent		Dropdown (Select-one)	Single	Y
			Very Good
			Good
			Fair
			Poor
AED06379		Have you completed this survey within the past 3 months?	Yes		Radio button, one-up vertical
			No			Single	N
			Don't recall

---

Sheet 24: Custom Qsts (09-24-09)

Model Instance Name: VA - My HealtheVet			red & strike-through: DELETE
MID:	NJxFtMU9UosBkJZRd48x9Q==		underlined & italicized: RE-ORDER
			pink: ADDITION
Date:	6/23/2009		blue + -->: REWORDING
			violet (bold): SKIP-LOGIC
MID: CUSTOM QUESTION LIST
QID	Skip Logic Label	Question Text	Answer Choices (limited to 50 characters)	Skip to	Type (select from list)	Single or Multi	Required Y/N
ALM0169		How frequently do you visit the My HealtheVet web site?	First time		Dropdown (Select-one)	Single	Y
			Daily
			More than once a day
			About once a week
			About once a month
			About every 6 months
			Less than every 6 months
ALM0170		Which of the following best describes you?	Active duty		Checkbox, one-up vertical	Multi	Y
			Veteran
			Family member of a veteran
			Veteran service organization
			News media
			General public
			VA employee
			Federal government employee
			State/local government employee
			Other role
RJB00048		Please indicate your military period(s) of service:	Global War on Terror (OEF/OIF)		Check-boxes	Multi	N
			Desert Shield/Desert Storm
			Vietnam War
			Korean War
			World War II
			Peacetime Service
			Other
			Not Applicable
RJB00022		What were you trying to accomplish today in My HealtheVet? (please select all that apply)	Enter/keep track of personal information (My Caregivers, etc.)		Check-boxes	Multi	Y
			Enter/keep track of personal health care information (blood pressure, blood sugar, etc.)
			Look up information about a medication
			Request a prescription refill
			Access prescription history from my VA medical record
			Find a VA health care facility
			Research a health condition
			Find information about VA Benefits
			Other (please specify)	A
RJB00022other	A	Other - trying to accomplish			Text field, <100 char	Single	N
ALM0172		Did you accomplish what you wanted to in My HealtheVet?	Yes		Dropdown (Select-one)	Single	Y
			No
			Partially
			Not finished yet
RJB00026		Are you a registered user on the MyHealtheVet web site?	Yes		Dropdown (Select-one)	Single	Y
			No
			Not sure
RJB00027		Have you visited your VA Facility in person to show your ID and be "in-person authenticated" (IPA) for My HealtheVet?	Yes		Dropdown (Select-one)	Single	Y
			No
			Not sure
			Not applicable
RJB00029		My use of the My HealtheVet personal health record has improved my ability to manage my health.	Strongly agree		Drop down, select one	Single	Y
			Agree
			Not sure
			Disagree
			Strongly disagree
			Not applicable
ALM0173		What is the main improvement that you would suggest for the My HealtheVet web site?			Open-ended	Single	N
		Have you ever visited the Healthy Living Spirituality Center?	Yes	A, B	Dropdown (Select-one)	Single	Y
			No	C
			Not sure
	A	How helpful did you find it?	Very helpful		Drop down, select one	Single	Y
			Somewhat helpful
			Undecided
			Not very helpful
			Not helpful at all
	B	Which parts were most useful to you? (Check all that apply)	Get Ready: Benefits of change, how to start healthy living, and special situations		Checkbox, one-up vertical	Multi	Y
			Self Management: Understand and track your progress through use of various tools
			Support and Encouragement: How a VA chaplain, local clergy, family and friends can support healthy living
			Caregiver Information: Caregiver resources and when to get additional help
			Related Topics: Body, mind and spirit connections
			None of the above
	C	Why did you not visit the Healthy Living Spirtuality Center?	Not interested		Drop down, select one	Single	Y
			Did not know about it
			Could not find it
		What spirituality resources would be of value to you as part of the Healthy Living Center? (check all that apply)	Article on a given topic	A	Checkbox, two-up vertical	Multi	Y
			Devotions or meditations
			Sample prayers
			Other, please specify	B
	A	What article topic would be of value to you?			Text area, no char limit
	B	What other spirituality resource would be of value to you?			Text area, no char limit
AKR5318		The VA is testing a program called The Daily Plan® at some VA facilities. The Daily Plan® provides patients (and/or family members, as appropriate) with a plan for each day in the hospital including information such as allergies, medications, diet, proced	Yes	A	Radio button, one-up vertical	Single	Y
			No
			Not sure
AKR5320	A	What information would you like to receive in your copy of The Daily Plan® (please check all that apply)	Current, active, and pending orders for my hospitalization		Checkbox, one-up vertical	Multi	N
			Allergies as stated in my VA medical record
			Current medications as stated in my VA medical record
			Upcoming procedures
			Upcoming VA appointments
			Diet orders
			Other	B
AKR5321	B	Other information			Text area, no char limit	Single	N
AKR5322		If you were admitted to a VA hospital, would you be interested in secure access to an electronic copy of The Daily Plan® on the TV screen in your room?	Yes		Radio button, one-up vertical	Single	Y
			No
			Not sure
AKR5323		The VA is developing an interactive patient television system that can provide patients with secure access to information and educational resources on the TV screen in their hospital room. Patients will also be able to learn more about their medical team,	Yes	A	Radio button, one-up vertical	Single	Y
			No
			Not sure
AKR5325	A	What information and services would you like access to using an interactive patient television system (please check all that apply)	Secure access to my VA medical record		Checkbox, one-up vertical	Multi	N
			My daily schedule while hospitalized
			Internet/Email access
			General education resources I can pick from
			Educational programs specific to my needs prescribed by my Health Care Team
			My HealtheVet Personal Health Record
			Information about my Health Care Team
			General information and news about my VA hospital
			A welcome message from VA Medical Center Leadership
			The ability to provide feedback about how my stay could be improved
			The ability to submit requests for items or services
			Other	B
AKR5326	B	Other Information for patient television system			Text area, no char limit	Single	N
KFB04531		The My HealtheVet website provides articles on topics of interest to Veterans. What topics are you most interested in for upcoming articles?			Text area, no char limit	Single	N
AED02714		What is your age range?	Under 20		Dropdown (Select-one)	Single	N
			20-24
			25-29
			30-34
			35-39
			40-44
			45-49
			50-54
			55-59
			60-64
			65-69
			70-74
			75-79
			80-84
			85 or older
JIC00267		What is your gender?	Male		Dropdown (Select-one)	Single	N
			Female
JIC00178		In general, how would you rate your overall health?	Excellent		Dropdown (Select-one)	Single	Y
			Very Good
			Good
			Fair
			Poor
AED06379		Have you completed this survey within the past 3 months?	Yes		Radio button, one-up vertical
			No			Single	N
			Don't recall

---

Sheet 25: Custom Qsts (8-11-09)

Model Instance Name: VA - My HealtheVet			red & strike-through: DELETE
MID:	NJxFtMU9UosBkJZRd48x9Q==		underlined & italicized: RE-ORDER
			pink: ADDITION
Date:	6/23/2009		blue + -->: REWORDING
			violet (bold): SKIP-LOGIC
MID: CUSTOM QUESTION LIST
QID	Skip Logic Label	Question Text	Answer Choices (limited to 50 characters)	Skip to	Type (select from list)	Single or Multi	Required Y/N
ALM0169		How frequently do you visit the My HealtheVet web site?	First time		Dropdown (Select-one)	Single	Y
			Daily
			More than once a day
			About once a week
			About once a month
			About every 6 months
			Less than every 6 months
ALM0170		Which of the following best describes you?	Active duty		Checkbox, one-up vertical	Multi	Y
			Veteran
			Family member of a veteran
			Veteran service organization
			News media
			General public
			VA employee
			Federal government employee
			State/local government employee
			Other role
RJB00048		Please indicate your military period(s) of service:	Global War on Terror (OEF/OIF)		Check-boxes	Multi	N
			Desert Shield/Desert Storm
			Vietnam War
			Korean War
			World War II
			Peacetime Service
			Other
			Not Applicable
RJB00022		What were you trying to accomplish today in My HealtheVet? (please select all that apply)	Enter/keep track of personal information (My Caregivers, etc.)		Check-boxes	Multi	Y
			Enter/keep track of personal health care information (blood pressure, blood sugar, etc.)
			Look up information about a medication
			Request a prescription refill
			Access prescription history from my VA medical record
			Find a VA health care facility
			Research a health condition
			Find information about VA Benefits
			Other (please specify)	A
RJB00022other	A	Other - trying to accomplish			Text field, <100 char	Single	N
ALM0172		Did you accomplish what you wanted to in My HealtheVet?	Yes		Dropdown (Select-one)	Single	Y
			No
			Partially
			Not finished yet
RJB00026		Are you a registered user on the MyHealtheVet web site?	Yes		Dropdown (Select-one)	Single	Y
			No
			Not sure
RJB00027		Have you visited your VA Facility in person to show your ID and be "in-person authenticated" (IPA) for My HealtheVet?	Yes		Dropdown (Select-one)	Single	Y
			No
			Not sure
			Not applicable
RJB00029		My use of the My HealtheVet personal health record has improved my ability to manage my health.	Strongly agree		Drop down, select one	Single	Y
			Agree
			Not sure
			Disagree
			Strongly disagree
			Not applicable
ALM0173		What is the main improvement that you would suggest for the My HealtheVet web site?			Open-ended	Single	N
		The VA is testing a program called The Daily Plan® at some VA facilities. The Daily Plan® provides patients (and/or family members, as appropriate) with a plan for each day in the hospital including information such as allergies, medications, diet, proced	Yes	A	Radio button, one-up vertical	Single	Y
			No
		If you were admitted to the VA hospital, would you be interested in receiving a paper copy of The Daily Plan® during your stay?	Not sure
	A	What information would you like to receive in your copy of The Daily Plan® (please check all that apply)	Current, active, and pending orders for my hospitalization		Checkbox, one-up vertical	Multi	N
			Allergies as stated in my VA medical record
			Current medications as stated in my VA medical record
			Upcoming procedures
			Upcoming VA appointments
			Diet orders
			Other	B
	B	Other information			Text area, no char limit
		If you were admitted to a VA hospital, would you be interested in secure access to an electronic copy of The Daily Plan® on the TV screen in your room?	Yes		Radio button, one-up vertical	Single	Y
			No
			Not sure
		The VA is developing an interactive patient television system that can provide patients with secure access to information and educational resources on the TV screen in their hospital room. Patients will also be able to learn more about their medical team, view their daily schedule, and make electronic requests for items like an extra pillow or a visit from the chaplain service.	Yes	A	Radio button, one-up vertical	Single
		If you were admitted to the VA hospital, would you be interested in using an interactive patient television system on the TV in your room during your stay?	No
			Not sure
.	A	What information and services would you like access to using an interactive patient television system (please check all that apply)	Secure access to my VA medical record		Checkbox, one-up vertical	Multi
			My daily schedule while hospitalized
			Internet/Email access
			General education resources I can pick from
			Educational programs specific to my needs prescribed by my Health Care Team
			My HealtheVet Personal Health Record
			Information about my Health Care Team
			General information and news about my VA hospital
			A welcome message from VA Medical Center Leadership
			The ability to provide feedback about how my stay could be improved
			The ability to submit requests for items or services
			Other	B
	B	Other Information for patient television system			Text area, no char limit	Single
		Have you discussed your My HealtheVet Personal Health Record with any of the following people? Please check all that apply:	I have not discussed my MyHealtheVet Personal Health Record with others.		Checkbox, one-up vertical	Multi	Y
			Your non-VA healthcare provider(s)
			Your family, friends, or loved ones
			Veterans you know
			Other (please specify)	A
KFB04533	A	Other person:			Text area, no char limit
KFB04534		How did you first learn about My HealtheVet? Was it from….	A VA health care provider or team?		Radio button, one-up vertical	Single	Y
			A non- VA health care provider?
			Someone who works at the VA BUT is not a healthcare provider?
			Information flyer or poster displayed within the VA?
			A veteran's organization or support group?
			An informational session presented either at the VA or elsewhere?
			Another veteran?
			A family member or a friend?
			Other (Please Specify)	A
KFB04535	A	Other way first learned:			Text area, no char limit
AED02714		What is your age range?	Under 20		Dropdown (Select-one)	Single	N
			20-24
			25-29
			30-34
			35-39
			40-44
			45-49
			50-54
			55-59
			60-64
			65-69
			70-74
			75-79
			80-84
			85 or older
JIC00267		What is your gender?	Male		Dropdown (Select-one)	Single	N
			Female
JIC00178		In general, how would you rate your overall health?	Excellent		Dropdown (Select-one)	Single	Y
			Very Good
			Good
			Fair
			Poor
JIC00728		Are you of Hispanic or Latino origin or descent?	Yes		Radio button, one-up vertical	Single	N
			No
JIC00729		What is your race?	American Indian or Alaska Native		Radio button, one-up vertical	Single	N
			Asian
			Black or African American
			Native Hawaiian or Other Pacific Islander
			White (Caucasian)
			Other, please specify	A
JIC00730	A	Other race			Text area, no char limit		N
JIC00731		Which of the following best describes the highest level of education you have completed?	Did not complete high school
			High school graduate		Radio button, one-up vertical	Single	N
			Some college or vocational school
			Current college or graduate student
			College graduate
			Some postgraduate school
			Graduate or professional degree
AED06379		Have you completed this survey within the past 3 months?	Yes
			No		Radio button, one-up vertical	Single	N
			Don't recall

---

Sheet 26: Custom Qsts 06-22-09

Model Instance Name: VA - My HealtheVet			red & strike-through: DELETE
MID:	NJxFtMU9UosBkJZRd48x9Q==		underlined & italicized: RE-ORDER
			pink: ADDITION
Date:	6/22/2009		blue + -->: REWORDING
			violet (bold): SKIP-LOGIC
MID: CUSTOM QUESTION LIST
QID	Skip Logic Label	Question Text	Answer Choices (limited to 50 characters)	Skip to	Type (select from list)	Single or Multi	Required Y/N
ALM0169		How frequently do you visit the My HealtheVet web site?	First time		Dropdown (Select-one)	Single	Y
			Daily
			More than once a day
			About once a week
			About once a month
			About every 6 months
			Less than every 6 months	A
JIC00732	A	Why don't you visit the My HealtheVet website more often?			Text area, no char limit	Single	N
ALM0170		Which of the following best describes you?	Active duty		Checkbox, one-up vertical	Multi	Y
			Veteran
			Family member of a veteran
			Veteran service organization
			News media
			General public
			VA employee
			Federal government employee
			State/local government employee
			Other role
RJB00048		Please indicate your military period(s) of service:	Global War on Terror (OEF/OIF)		Check-boxes	Multi	N
			Desert Shield/Desert Storm
			Vietnam War
			Korean War
			World War II
			Peacetime Service
			Other
			Not Applicable
RJB00022		What were you trying to accomplish today in My HealtheVet? (please select all that apply)	Enter/keep track of personal information (My Caregivers, etc.)		Check-boxes	Multi	Y
			Enter/keep track of personal health care information (blood pressure, blood sugar, etc.)
			Look up information about a medication
			Request a prescription refill
			Access prescription history from my VA medical record
			Find a VA health care facility
			Research a health condition
			Find information about VA Benefits
			Other (please specify)	A
RJB00022other	A	Other - trying to accomplish			Text field, <100 char	Single	N
ALM0172		Did you accomplish what you wanted to in My HealtheVet?	Yes		Dropdown (Select-one)	Single	Y
			No
			Partially
			Not finished yet
RJB00026		Are you a registered user on the MyHealtheVet web site?	Yes		Dropdown (Select-one)	Single	Y
			No
			Not sure
RJB00027		Have you visited your VA Facility in person to show your ID and be "in-person authenticated" (IPA) for My HealtheVet?	Yes	A	Dropdown (Select-one)	Single	Y
			No	C
			Not sure
			Not applicable
AED06361	A	How did you hear about In Person Authentication (check all that apply)	I read about it at the My HealtheVet website		Checkbox, one-up vertical	Multi	Y
			I heard about it from a VA Staff member
			I heard about it from another Veteran
			I read about it at the My HealtheVet website
			I read about it in an article or brochure
			I was authenticated as I registered for My HealtheVet at a VA Facility
			Other Please specify	B
AED06362	B	Other way heard about IPA, please specify			Text area, no char limit		N
AED06363	C	If no, why not? (check all that apply)	I have not visited my VA Facility recently		Checkbox, one-up vertical	Multi	Y
			I was not aware that I needed to become In Person Authenticated
			I am not sure about the benefits of becoming In Person Authenticated
			I do not understand what is meant by "In Person Authentication"
			I am not sure how to become In Person Authenticated at my VA Facility
			Other Please specify	D
AED06364	D	Other reason why not, please specify
RJB00029		My use of the My HealtheVet personal health record has improved my ability to manage my health.	Strongly agree		Drop down, select one	Single	Y
			Agree
			Not sure
			Disagree
			Strongly disagree
			Not applicable
ALM0173		What is the main improvement that you would suggest for the My HealtheVet web site?			Open-ended	Single	N
AED06365		We are interested in what interactive features might be useful for veterans in the future. Please indicate which features you would be most likely to use (check all that apply):	Online message boards to post and view messages about various health topics		Checkbox, one-up vertical	Multi	Y
			Online support group meeting focused on a specific health topic with a health professional at a specific time
			Online chat rooms to interact with others
			Online blogs to read posts from VA staff and make comments
			"Ask an Expert" type feature which enables you to post a question in a discussion board and view responses
			None of the above
AED06366		Have you ever used the general My HealtheVet “Help” tab which is located at the top right of each page?	Yes	A, B	Drop down, select one	Single	Y
			No	D
			Don't know
AED06367	A	The general "Help" tab provided the information that I needed.	Strongly agree		Drop down, select one	Single	Y
			Agree
			Not sure
			Disagree
			Strongly disagree
AED06368	B	Please tell us about your experience in using the general "Help" tab (check all that apply):	"Help" did provide the specific information I was looking for		Drop down, select one	Single	Y
			"Help" did not provide the specific information I was looking for
			I had no difficulty using "Help" on this site
			Too much information was provided by "Help"
			Too little information was provided by "Help"
			Other experience with "Help" (please specify):	C
AED06369	C	Other "Help" experience, please specify			Text area, no char limit		N
AED06370	D	If no, why not?	Did not need help information		Drop down, select one	Single	N
			Was not aware that help information was available
			Did not notice the "Help" tab
			Tried to find information by browsing the site
			Tried to find information by searching the site
			Not sure
AED06371		For users who are logged-in to the site, some sections of the site link to topic-specific help. Have you ever used the topic-specific My HealtheVet “Help” link from an individual page (located next to “printer-friendly” link on some pages)?	Yes	A, B	Drop down, select one	Single	Y
			No	D
			Don't know
AED06372	A	The topic-specific "Help" link provided the information that I needed.	Strongly agree		Drop down, select one	Single	Y
			Agree
			Not sure
			Disagree
			Strongly disagree
AED06373	B	Please tell us about your experience in using the topic-specific "Help" link (check all that apply):	"Help" did provide the specific information I was looking for		Drop down, select one	Single	Y
			"Help" did not provide the specific information I was looking for
			I had no difficulty using "Help" on this site
			Too much information was provided by the "Help" link
			Too little information was provided by the "Help" link
			Other experience with "Help" (please specify):	C
AED06374	C	Other topic-specific "Help" experience, please specify			Text area, no char limit		N
AED06375	D	If no, why not?	Did not need help information		Drop down, select one	Single	N
			Was not aware that help information was available
			Did not notice the "Help" link
			Tried to find information by browsing the site
			Tried to find information by searching the site
			Not sure
AED06376		My HealtheVet users can provide an email address when registering for an account and update this email address in their account preferences. Which of the following kinds of contact would you prefer to receive using this email address (check all that apply)?	General updates about new My HealtheVet content and features		Checkbox, one-up vertical	Multi	Y
			Periodic electronic newsletters which include tips for using My HealtheVet features
			Topic-specific messages customized for health or condition interests you've selected in your preferences
			Notification messages that alert you that a new secure message is available in the My HealtheVet portal
			Other (please specify)	A
AED06377	A	Other email information, please specify
AED06378		If you are a VA patient, in the future you will be able to send a secure message to your VA healthcare team through the My HealtheVet portal. Which of the following kinds of contact would you prefer using secure messaging (Check all that apply):	Responses to my health care questions from my health care team		Checkbox, one-up vertical	Multi	Y
			Responses to my administrative questions from my health care team
			Responses to my questions about lab or test results
			Responses to my questions about medications or prescriptions
			Responses to my questions about lab or test results
			Responses to my prescription renewal requests
			Responses to my requests to schedule or change my VA appointment
			Reminders about upcoming VA appointments
			Notify my health care team of changes to my mailing address
			I am not currently a VA patient.
		The My HealtheVet website provides articles on topics of interest to Veterans. What topics are you most interested in for upcoming articles?			Text area, no char limit	Single	N
		Have you discussed your My HealtheVet Personal Health Record with any of the following people? Please check all that apply:	I have not discussed my MyHealtheVet Personal Health Record with others.		Checkbox, one-up vertical	Multi	Y
			Your VA healthcare provider(s) or team
			Your non-VA healthcare provider(s)
			Your family, friends, or loved ones
			Veterans you know
			Other (please specify)	A
	A	Other person:			Text area, no char limit
		How did you first learn about My HealtheVet? Was it from….	A VA health care provider or team?		Radio button, one-up vertical	Single	Y
			A non- VA health care provider?
			Someone who works at the VA BUT is not a healthcare provider?
			Information flyer or poster displayed within the VA?
			A veteran's organization or support group?
			An informational session presented either at the VA or elsewhere?
			Another veteran?
			A family member or a friend?
			Other (Please Specify)	A
	A	Other way first learned:			Text area, no char limit
AED02714		What is your age range?	Under 20		Dropdown (Select-one)	Single	N
			20-24
			25-29
			30-34
			35-39
			40-44
			45-49
			50-54
			55-59
			60-64
			65-69
			70-74
			75-79
			80-84
			85 or older
JIC00267		What is your gender?	Male		Dropdown (Select-one)	Single	N
			Female
JIC00178		In general, how would you rate your overall health?	Excellent		Dropdown (Select-one)	Single	Y
			Very Good
			Good
			Fair
			Poor
JIC00728		Are you of Hispanic or Latino origin or descent?	Yes		Radio button, one-up vertical	Single	N
			No
JIC00729		What is your race?	American Indian or Alaska Native		Radio button, one-up vertical	Single	N
			Asian
			Black or African American
			Native Hawaiian or Other Pacific Islander
			White (Caucasian)
			Other, please specify	A
JIC00730	A	Other race			Text area, no char limit		N
JIC00731		Which of the following best describes the highest level of education you have completed?	Did not complete high school
			High school graduate		Radio button, one-up vertical	Single	N
			Some college or vocational school
			Current college or graduate student
			College graduate
			Some postgraduate school
			Graduate or professional degree
AED06379		Have you completed this survey within the past 3 months?	Yes
			No		Radio button, one-up vertical	Single	N
			Don't recall

---

Sheet 27: Custom Qsts 02-17-09

Model Instance Name: VA - My HealtheVet			red & strike-through: DELETE
MID:	NJxFtMU9UosBkJZRd48x9Q==		underlined & italicized: RE-ORDER
			pink: ADDITION
Date:	2/17/2009		blue + -->: REWORDING
			violet (bold): SKIP-LOGIC
MID: CUSTOM QUESTION LIST
QID	Skip Logic Label	Question Text	Answer Choices (limited to 50 characters)	Skip to	Type (select from list)	Single or Multi	Required Y/N
ALM0169		How frequently do you visit the My HealtheVet web site?	First time		Dropdown (Select-one)	Single	Y
			Daily
			More than once a day
			About once a week
			About once a month
			About every 6 months
			Less than every 6 months	A
JIC00732	A	Why don't you visit the My HealtheVet website more often?			Text area, no char limit	Single	N
ALM0170		Which of the following best describes you?	Active duty		Checkbox, one-up vertical	Multi	Y
			Veteran
			Family member of a veteran
			Veteran service organization
			News media
			General public
			VA employee
			Federal government employee
			State/local government employee
			Other role
RJB00048		Please indicate your military period(s) of service:	Global War on Terror (OEF/OIF)		Check-boxes	Multi	N
			Desert Shield/Desert Storm
			Vietnam War
			Korean War
			World War II
			Peacetime Service
			Other
			Not Applicable
RJB00022		What were you trying to accomplish today in My HealtheVet? (please select all that apply)	Enter/keep track of personal information (My Caregivers, etc.)		Check-boxes	Multi	Y
			Enter/keep track of personal health care information (blood pressure, blood sugar, etc.)
			Look up information about a medication
			Request a prescription refill
			Access prescription history from my VA medical record
			Find a VA health care facility
			Research a health condition
			Find information about VA Benefits
			Other (please specify) (skip to A)
RJB00022other	A	Other - trying to accomplish			Text field, <100 char	Single	N
ALM0172		Did you accomplish what you wanted to in My HealtheVet?	Yes		Dropdown (Select-one)	Single	Y
			No
			Partially
			Not finished yet
RJB00026		Are you a registered user on the MyHealtheVet web site?	Yes		Dropdown (Select-one)	Single	Y
			No
			Not sure
RJB00027		Have you visited your VA Facility in person to show your ID and be "in-person authenticated" (IPA) for My HealtheVet?	Yes	A	Dropdown (Select-one)	Single	Y
			No	C
			Not sure
			Not applicable
	A	How did you hear about In Person Authentication (check all that apply)	I read about it at the My HealtheVet website		Checkbox, one-up vertical	Multi	Y
			I heard about it from a VA Staff member
			I heard about it from another Veteran
			I read about it at the My HealtheVet website
			I read about it in an article or brochure
			I was authenticated as I registered for My HealtheVet at a VA Facility
			Other Please specify__________________	B
	B	Other way heard about IPA, please specify			Text area, no char limit		N
	C	If no, why not? (check all that apply)	I have not visited my VA Facility recently		Checkbox, one-up vertical	Multi	Y
			I was not aware that I needed to become In Person Authenticated
			I am not sure about the benefits of becoming In Person Authenticated
			I do not understand what is meant by "In Person Authentication"
			I am not sure how to become In Person Authenticated at my VA Facility
			Other Please specify__________________	D
	D	Other reason why not, please specify
RJB00029		My use of the My HealtheVet personal health record has improved my ability to manage my health.	Strongly agree		Drop down, select one	Single	Y
			Agree
			Not sure
			Disagree
			Strongly disagree
			Not applicable
ALM0173		What is the main improvement that you would suggest for the My HealtheVet web site?			Open-ended	Single	N
		We are interested in what interactive features might be useful for veterans in the future. Please indicate which features you would be most likely to use (check all that apply):	Online message boards to post and view messages about various health topics		Checkbox, one-up vertical	Multi	Y
			Online support group meeting focused on a specific health topic with a health professional at a specific time
			Online chat rooms to interact with others
			Online blogs to read posts from VA staff and make comments
			"Ask an Expert" type feature which enables you to post a question in a discussion board and view responses
			None of the above
		Have you ever used the general My HealtheVet “Help” tab which is located at the top right of each page?	Yes	A, B	Drop down, select one	Single	Y
			No	D
			Don't know
	A	The general "Help" tab provided the information that I needed.	Strongly agree		Drop down, select one	Single	Y
			Agree
			Not sure
			Disagree
			Strongly disagree
	B	Please tell us about your experience in using the general "Help" tab (check all that apply):	"Help" did provide the specific information I was looking for		Drop down, select one	Single	Y
			"Help" did not provide the specific information I was looking for
			I had no difficulty using "Help" on this site
			Too much information was provided by "Help"
			Too little information was provided by "Help"
			Other experience with "Help" (please specify):	C
	C	Other "Help" experience, please specify			Text area, no char limit		N
	D	If no, why not?	Did not need help information		Drop down, select one	Single	N
			Was not aware that help information was available
			Did not notice the "Help" tab
			Tried to find information by browsing the site
			Tried to find information by searching the site
			Not sure
		For users who are logged-in to the site, some sections of the site link to topic-specific help. Have you ever used the topic-specific My HealtheVet “Help” link from an individual page (located next to “printer-friendly” link on some pages)?	Yes	A, B	Drop down, select one	Single	Y
			No	D
			Don't know
	A	The topic-specific "Help" link provided the information that I needed.	Strongly agree		Drop down, select one	Single	Y
			Agree
			Not sure
			Disagree
			Strongly disagree
	B	Please tell us about your experience in using the topic-specific "Help" link (check all that apply):	"Help" did provide the specific information I was looking for		Drop down, select one	Single	Y
			"Help" did not provide the specific information I was looking for
			I had no difficulty using "Help" on this site
			Too much information was provided by the "Help" link
			Too little information was provided by the "Help" link
			Other experience with "Help" (please specify):	C
	C	Other topic-specific "Help" experience, please specify			Text area, no char limit		N
	D	If no, why not?	Did not need help information		Drop down, select one	Single	N
			Was not aware that help information was available
			Did not notice the "Help" link
			Tried to find information by browsing the site
			Tried to find information by searching the site
			Not sure
		My HealtheVet users can provide an email address when registering for an account and update this email address in their account preferences. Which of the following kinds of contact would you prefer to receive using this email address (check all that apply	General updates about new My HealtheVet content and features		Checkbox, one-up vertical	Multi	Y
			Periodic electronic newsletters which include tips for using My HealtheVet features
			Topic-specific messages customized for health or condition interests you've selected in your preferences
			Notification messages that alert you that a new secure message is available in the My HealtheVet portal
			Other (please specify)	A
	A	Other email information, please specify
		If you are a VA patient, in the future you will be able to send a secure message to your VA healthcare team through the My HealtheVet portal. Which of the following kinds of contact would you prefer using secure messaging (Check all that apply):	Responses to my health care questions from my health care team		Checkbox, one-up vertical	Multi	Y
			Responses to my administrative questions from my health care team
			Responses to my questions about lab or test results
			Responses to my questions about medications or prescriptions
			Responses to my questions about lab or test results
			Responses to my prescription renewal requests
			Responses to my requests to schedule or change my VA appointment
			Reminders about upcoming VA appointments
			Notify my health care team of changes to my mailing address
			I am not currently a VA patient.
AED02714		What is your age range?	Under 20		Dropdown (Select-one)	Single	N
			20-24
			25-29
			30-34
			35-39
			40-44
			45-49
			50-54
			55-59
			60-64
			65-69
			70-74
			75-79
			80-84
			85 or older
JIC00267		What is your gender?	Male		Dropdown (Select-one)	Single	N
			Female
JIC00178		In general, how would you rate your overall health?	Excellent		Dropdown (Select-one)	Single	Y
			Very Good
			Good
			Fair
			Poor
JIC00715		If your doctor recommends that you get a blood sugar test for diabetes, how likely is it that you will get the test?	very likely		Radio button, one-up vertical	Single	N
			somewhat likely
			not very likely
			not at all likely
			I've already been tested
JIC00716		If your doctor recommends that you get a cholesterol blood test, how likely is it that you will get the test?	very likely		Radio button, one-up vertical	Single	N
			somewhat likely
			not very likely
			not at all likely
			I've already been tested
JIC00717		If your doctor recommends that you get a Hepatitis C blood test, how likely is it that you will get the test?	very likely		Radio button, one-up vertical	Single	N
			somewhat likely
			not very likely
			not at all likely
			I've already been tested
JIC00718		If your doctor recommends that you get an HIV blood test, how likely is it that you will get the test?	very likely		Radio button, one-up vertical	Single	N
			somewhat likely
			not very likely
			not at all likely
			I've already been tested
JIC00719		Which of the following health screening tests have you been offered in the last 12 months? (select all that apply)	blood sugar test for diabetes		Checkbox, one-up vertical	Multi	N
			cholesterol blood test
			Hepatitis C blood test
			HIV blood test	A, C
			none of the above
JIC00720	A	Who offered you the HIV blood test?	VA primary care provider		Checkbox, one-up vertical	Multi	N
		(select all that apply)	VA mental health provider
			Other VA Medical Center staff member
			Other VA Outpatient clinic staff member
			Non-VA Health care provider
			Community resource or health fair
			Unsure / Don't Know
			Other (please specify)	B
JIC00721	B	Other person			Text area, no char limit		N
JIC00722	C	Did you have the HIV test done?	Yes	D	Radio button, one-up vertical	Single	N
			No	E
JIC00723	D	Did you receive your HIV test results?	Yes		Radio button, one-up vertical	Single	N
			No
JIC00724	E	If you did not have the HIV test done, what influenced your decision? (select all that apply)	I have already been tested recently		Checkbox, one-up vertical	Multi	N
			I don't feel that I am at risk
			I have concerns about confidentiality
			I don't like needles or giving blood
			I'm afraid that I could test positive
			I don't have time to be tested
			I'm not sure about how to get tested
			Other reason, please specify	F
JIC00733	F	Other reason, please specify			Text area, no char limit		N
JIC00725		Which of the following health screening tests have you had in the last 12 months? (select all that apply)	Blood sugar test for diabetes		Checkbox, one-up vertical	Multi	N
			Cholesterol blood test
			Hepatitis C blood test
			HIV blood test
			none of the above
JIC00726		How would you like to receive more information about health screening tests? (select all that apply)	Personal contact (in person or on phone) from my doctor or health care team		Checkbox, one-up vertical	Multi	N
			Email from my doctor or health care team
			Email from VA or My HealtheVet
			Information available on the My HealtheVet website
			Posters at a VA medical center
			Health fair or education session
			Handout given to me by my doctor or health care team
			Other, please specify	A
JIC00727	A	Other method			Text area, no char limit		N
JIC00728		Are you of Hispanic or Latino origin or descent?	Yes		Radio button, one-up vertical	Single	N
			No
JIC00729		What is your race?	American Indian or Alaska Native		Radio button, one-up vertical	Single	N
			Asian
			Black or African American
			Native Hawaiian or Other Pacific Islander
			White (Caucasian)
			Other, please specify	A
JIC00730	A	Other race			Text area, no char limit		N
JIC00731		Which of the following best describes the highest level of education you have completed?	Did not complete high school
			High school graduate		Radio button, one-up vertical	Single	N
			Some college or vocational school
			Current college or graduate student
			College graduate
			Some postgraduate school
			Graduate or professional degree
		Have you completed this survey within the past 3 months?	Yes
			No		Radio button, one-up vertical	Single	N
			Don't recall

---

Sheet 28: Custom Qsts (10-20-08)

Model Instance Name: VA - My HealtheVet			red & strike-through: DELETE
MID:	NJxFtMU9UosBkJZRd48x9Q==		underlined & italicized: RE-ORDER
			pink: ADDITION
Date:	3/1/2008		blue + -->: REWORDING
			violet (bold): SKIP-LOGIC
MID: CUSTOM QUESTION LIST
QID	Skip Logic Label	Question Text	Answer Choices (limited to 50 characters)	Skip to	Type (select from list)	Single or Multi	Required Y/N
ALM0169		How frequently do you visit the My HealtheVet web site?	First time		Dropdown (Select-one)	Single	Y
			Daily
			More than once a day
			About once a week
			About once a month
			About every 6 months
			Less than every 6 months	A
JIC00732	A	Why don't you visit the My HealtheVet website more often?			Text area, no char limit	Single	N
ALM0170		Which of the following best describes you?	Active duty		Checkbox, one-up vertical	Multi	Y
			Veteran
			Family member of a veteran
			Veteran service organization
			News media
			General public
			VA employee
			Federal government employee
			State/local government employee
			Other role
RJB00048		Please indicate your military period(s) of service:	Global War on Terror (OEF/OIF)		Check-boxes	Multi	N
			Desert Shield/Desert Storm
			Vietnam War
			Korean War
			World War II
			Peacetime Service
			Other
			Not Applicable
RJB00022		What were you trying to accomplish today in My HealtheVet? (please select all that apply)	Enter/keep track of personal information (My Caregivers, etc.)		Check-boxes	Multi	Y
			Enter/keep track of personal health care information (blood pressure, blood sugar, etc.)
			Look up information about a medication
			Request a prescription refill
			Access prescription history from my VA medical record
			Find a VA health care facility
			Research a health condition
			Find information about VA Benefits
			Other (please specify) (skip to A)
RJB00022other	A	Other - trying to accomplish			Text field, <100 char	Single	N
ALM0172		Did you accomplish what you wanted to in My HealtheVet?	Yes		Dropdown (Select-one)	Single	Y
			No
			Partially
			Not finished yet
RJB00026		Are you a registered user on the MyHealtheVet web site?	Yes		Dropdown (Select-one)	Single	Y
			No
			Not sure
RJB00027		Have you visited your VA Facility in person to show your ID and be "in-person authenticated" (IPA) for My HealtheVet?	Yes		Dropdown (Select-one)	Single	Y
			No
			Not sure
			Not applicable
RJB00029		My use of the My HealtheVet personal health record has improved my ability to manage my health.	Strongly agree		Drop down, select one	Single	Y
			Agree
			Not sure
			Disagree
			Strongly disagree
			Not applicable
ALM0173		What is the main improvement that you would suggest for the My HealtheVet web site?			Open-ended	Single	N
AED02714		What is your age range?	Under 20		Dropdown (Select-one)	Single	N
			20-24
			25-29
			30-34
			35-39
			40-44
			45-49
			50-54
			55-59
			60-64
			65-69
			70-74
			75-79
			80-84
			85 or older
JIC00267		What is your gender?	Male		Dropdown (Select-one)	Single	N
			Female
JIC00178		In general, how would you rate your overall health?	Excellent		Dropdown (Select-one)	Single	Y
			Very Good
			Good
			Fair
			Poor
JIC00715		If your doctor recommends that you get a blood sugar test for diabetes, how likely is it that you will get the test?	very likely		Radio button, one-up vertical	Single	N
			somewhat likely
			not very likely
			not at all likely
			I've already been tested
JIC00716		If your doctor recommends that you get a cholesterol blood test, how likely is it that you will get the test?	very likely		Radio button, one-up vertical	Single	N
			somewhat likely
			not very likely
			not at all likely
			I've already been tested
JIC00717		If your doctor recommends that you get a Hepatitis C blood test, how likely is it that you will get the test?	very likely		Radio button, one-up vertical	Single	N
			somewhat likely
			not very likely
			not at all likely
			I've already been tested
JIC00718		If your doctor recommends that you get an HIV blood test, how likely is it that you will get the test?	very likely		Radio button, one-up vertical	Single	N
			somewhat likely
			not very likely
			not at all likely
			I've already been tested
JIC00719		Which of the following health screening tests have you been offered in the last 12 months? (select all that apply)	blood sugar test for diabetes		Checkbox, one-up vertical	Multi	N
			cholesterol blood test
			Hepatitis C blood test
			HIV blood test	A, C
			none of the above
JIC00720	A	Who offered you the HIV blood test?	VA primary care provider		Checkbox, one-up vertical	Multi	N
		(select all that apply)	VA mental health provider
			Other VA Medical Center staff member
			Other VA Outpatient clinic staff member
			Non-VA Health care provider
			Community resource or health fair
			Unsure / Don't Know
			Other (please specify)	B
JIC00721	B	Other person			Text area, no char limit		N
JIC00722	C	Did you have the HIV test done?	Yes	D	Radio button, one-up vertical	Single	N
			No	E
JIC00723	D	Did you receive your HIV test results?	Yes		Radio button, one-up vertical	Single	N
			No
JIC00724	E	If you did not have the HIV test done, what influenced your decision? (select all that apply)	I have already been tested recently		Checkbox, one-up vertical	Multi	N
			I don't feel that I am at risk
			I have concerns about confidentiality
			I don't like needles or giving blood
			I'm afraid that I could test positive
			I don't have time to be tested
			I'm not sure about how to get tested
			Other reason, please specify
JIC00725		Which of the following health screening tests have you had in the last 12 months? (select all that apply)	Blood sugar test for diabetes		Checkbox, one-up vertical	Multi	N
			Cholesterol blood test
			Hepatitis C blood test
			HIV blood test
			none of the above
JIC00726		How would you like to receive more information about health screening tests? (select all that apply)	Personal contact (in person or on phone) from my doctor or health care team		Checkbox, one-up vertical	Multi	N
			Email from my doctor or health care team
			Email from VA or My HealtheVet
			Information available on the My HealtheVet website
			Posters at a VA medical center
			Health fair or education session
			Handout given to me by my doctor or health care team
			Other, please specify	A
JIC00727	A	Other method			Text area, no char limit		N
JIC00728		Are you of Hispanic or Latino origin or descent?	Yes		Radio button, one-up vertical	Single	N
			No
JIC00729		What is your race?	American Indian or Alaska Native		Radio button, one-up vertical	Single	N
			Asian
			Black or African American
			Native Hawaiian or Other Pacific Islander
			White (Caucasian)
			Other, please specify	A
JIC00730	A	Other race			Text area, no char limit		N
JIC00731		Which of the following best describes the highest level of education you have completed?	Did not complete high school
			High school graduate		Radio button, one-up vertical	Single	N
			Some college or vocational school
			Current college or graduate student
			College graduate
			Some postgraduate school
			Graduate or professional degree

---

Sheet 29: Custom Qsts (10-17-2008)

Model Instance Name: VA - My HealtheVet			red & strike-through: DELETE
MID:	NJxFtMU9UosBkJZRd48x9Q==		underlined & italicized: RE-ORDER
			pink: ADDITION
Date:	10/17/2008		blue + -->: REWORDING
			violet (bold): SKIP-LOGIC
MID: CUSTOM QUESTION LIST
QID	Skip Logic Label	Question Text	Answer Choices (limited to 50 characters)	Skip to	Type (select from list)	Single or Multi	Required Y/N
ALM0169		How frequently do you visit the My HealtheVet web site?	First time		Dropdown (Select-one)	Single	Y
			Daily
			More than once a day
			About once a week
			About once a month
			About every 6 months
			Less than every 6 months	A
	A	Why don't you visit the My HealtheVet website more often?			Text area, no char limit	Single	N
RJB00080		Please rate your ability in using the Internet:	Beginner or novice (just starting/don't use Internet much)		Radio button, one-up vertical	Single	Y
			Intermediate (use the Internet for a few things)
			Advanced (frequently use Internet & search for information)
ALM0170		Which of the following best describes you?	Active duty		Checkbox, one-up vertical	Multi	Y
			Veteran
			Family member of a veteran
			Veteran service organization
			News media
			General public
			VA employee
			Federal government employee
			State/local government employee
			Other role
RJB00048		Please indicate your military period(s) of service:	Global War on Terror (OEF/OIF)		Check-boxes	Multi	N
			Desert Shield/Desert Storm
			Vietnam War
			Korean War
			World War II
			Peacetime Service
			Other
			Not Applicable
RJB00022		What were you trying to accomplish today in My HealtheVet? (please select all that apply)	Enter/keep track of personal information (My Caregivers, etc.)		Check-boxes	Multi	Y
			Enter/keep track of personal health care information (blood pressure, blood sugar, etc.)
			Look up information about a medication
			Request a prescription refill
			Access prescription history from my VA medical record
			Find a VA health care facility
			Research a health condition
			Find information about VA Benefits
			Other (please specify) (skip to A)
RJB00022other	A	Other - trying to accomplish			Text field, <100 char	Single	N
ALM0172		Did you accomplish what you wanted to in My HealtheVet?	Yes		Dropdown (Select-one)	Single	Y
			No
			Partially
			Not finished yet
RJB00068		If you did not accomplish what you wanted to, what will you do next?	Continue looking on My HealtheVet		Radio Button One Up Vertical	Single	N
			Come back to My HealtheVet later
			E-mail the Veterans Health Administration
			Call the Veterans Health Administration
			Look elsewhere online
			Give up
			Other
RJB00024		What additional services would you like to see on My HealtheVet? (please select all that apply)	View my upcoming appointments		Check-boxes	Multi	N
			Schedule or change my appointments
			Advance check in for my VA clinic visits
			Online, secure communication with my doctor
			Look at information in my VA medical record
			Share information I have stored in My HealtheVet with other people (e.g., family or doctor)
			Reminders of preventive care I need (e.g., shots, cancer screening)
			Checking that different medications I take are safe when used together
			Educational programs
			Monthly email newsletter
			Notification of new content/features on the site
			Information about the quality of VA health care
			Advanced directive (e.g. living will, durable power of attorney for health care)
			Other (please specify): (skip to A)
RJB00024other	A	Other - additional services			Text field, <100 char	Single	N
RJB00070		Please describe your experience with navigation on this web site.	I had no difficulty navigating on this site		Check-boxes	Multi	Y
			Too many buttons or links to other places
			Links did not take me where I expected
			I experienced links that went nowhere, error messages, or other technical difficulties
			I was able to find general information, but could not find the specific content that I needed
			Other navigational issue (please specify): (skip to A)
RJB00070other	A	Other navigational issue			Text field, <100 char	Single	N
RJB00071		Did you use the web site's search feature today?	Yes (skip to C)		Dropdown (Select-one)	Single	Y
			No (skip to A)
JIC00265	A	Why did you not use the search feature?	Prefer other method of navigation		Check-boxes	Multi	Y
			Tried to use search but was unsuccessful
			Did not need search, found information quickly
			Other (please specify) (skip to B)
JIC00266	B	Other reasons why not used the search feature:
JIC00176	C	Please describe your experience with the site's search feature.	I had no difficulty using the search feature on this site		Check-boxes	Multi	Y
			Could not tell what information the search results would take me to
			Too many results
			Too few results
			Returned no results/received error message
			Results were not related to what I was looking for
			Other search issue (please specify): (skip to D)
JIC00177	D	Other experience with the site's search feature:
RJB00026		Are you a registered user on the MyHealtheVet web site?	Yes		Dropdown (Select-one)	Single	Y
			No
			Not sure
RJB00027		Have you visited your VA Facility in person to show your ID and be "in-person authenticated" (IPA) for My HealtheVet?	Yes		Dropdown (Select-one)	Single	Y
			No
			Not sure
			Not applicable
RJB00082		How much time would it take for you to travel to the nearest VA facility?	Less than 15 minutes		Drop down, select one	Single	N
			15 minutes to less than 1/2 hour
			1/2 hour to less than an hour
			An hour to less than 1 1/2 hours
			1 1/2 hours to less than two hours
			Two hours or more
			Not sure
RJB00029		My use of the My HealtheVet personal health record has improved my ability to manage my health.	Strongly agree		Drop down, select one	Single	Y
			Agree
			Not sure
			Disagree
			Strongly disagree
			Not applicable
ALM0173		What is the main improvement that you would suggest for the My HealtheVet web site?			Open-ended	Single	N
JIC00268		Did you use a VA medical facility or service for any of your health care needs in the last 12 months?	Yes		Dropdown (Select-one)	Single	Y
			No
JIC00269		In the last 12 months, where did you go for most of your routine outpatient care? (choose one that best fits your answer)	VA hospital or clinic		Dropdown (Select-one)	Single	Y
			A non-VA hospital or clinic
			Did not receive routine care or services in the past year
			Don't know
JIC00270		If you have used urgent care or the emergency room in the last 12 months, where do you typically go? (choose one that best fits your answer)	A VA hospital or clinic		Dropdown (Select-one)	Single	Y
			A non-VA hospital or clinic
			Did not use urgent care or an emergency room in the past year
			Don't know
AED02714		What is your age range?	Under 20		Dropdown (Select-one)	Single	N
			20-24
			25-29
			30-34
			35-39
			40-44
			45-49
			50-54
			55-59
			60-64
			65-69
			70-74
			75-79
			80-84
			85 or older
JIC00267		What is your gender?	Male		Dropdown (Select-one)	Single	N
			Female
JIC00178		In general, how would you rate your overall health?	Excellent		Dropdown (Select-one)	Single	Y
			Very Good
			Good
			Fair
			Poor
ALM0032		In which state do you currently reside?	Alabama		Dropdown (Select-one)	Single	N
			Alaska
			Arizona
			Arkansas
			California
			Colorado
			Connecticut
			Delaware
			Florida
			Georgia
			Hawaii
			Idaho
			Illinois
			Indiana
			Iowa
			Kansas
			Kentucky
			Louisiana
			Maine
			Maryland
			Massachusetts
			Michigan
			Minnesota
			Mississippi
			Missouri
			Montana
			Nebraska
			Nevada
			New Hampshire
			New Jersey
			New Mexico
			New York
			North Carolina
			North Dakota
			Ohio
			Oklahoma
			Oregon
			Pennsylvania
			Rhode Island
			South Carolina
			South Dakota
			Tennessee
			Texas
			Utah
			Vermont
			Virginia
			Washington
			Washington D.C.
			West Virginia
			Wisconsin
			Wyoming
			Canada
			I live elsewhere
		If your doctor recommends that you get a blood sugar test for diabetes, how likely is it that you will get the test?	very likely		Radio button, one-up vertical	Single	N
			somewhat likely
			not very likely
			not at all likely
			I've already been tested
		If your doctor recommends that you get a cholesterol blood test, how likely is it that you will get the test?	very likely		Radio button, one-up vertical	Single	N
			somewhat likely
			not very likely
			not at all likely
			I've already been tested
		If your doctor recommends that you get a Hepatitis C blood test, how likely is it that you will get the test?	very likely		Radio button, one-up vertical	Single	N
			somewhat likely
			not very likely
			not at all likely
			I've already been tested
		If your doctor recommends that you get an HIV blood test, how likely is it that you will get the test?	very likely		Radio button, one-up vertical	Single	N
			somewhat likely
			not very likely
			not at all likely
			I've already been tested
		Which of the following health screening tests have you been offered in the last 12 months? (select all that apply)	blood sugar test for diabetes		Checkbox, one-up vertical	Multi	N
			cholesterol blood test
			Hepatitis C blood test
			HIV blood test	A, C
			none of the above
	A	Who offered you the HIV blood test?	VA primary care provider		Checkbox, one-up vertical	Multi	N
		(select all that apply)	VA mental health provider
			Other VA Medical Center staff member
			Other VA Outpatient clinic staff member
			Non-VA Health care provider
			Community resource or health fair
			Unsure / Don't Know
			Other (please specify)	B
	B	Other person			Text area, no char limit		N
	C	Did you have the HIV test done?	Yes	D	Radio button, one-up vertical	Single	N
			No	E
	D	Did you receive your HIV test results?	Yes		Radio button, one-up vertical	Single	N
			No
	E	If you did not have the HIV test done, what influenced your decision? (select all that apply)	I have already been tested recently		Checkbox, one-up vertical	Multi	N
			I don't feel that I am at risk
			I have concerns about confidentiality
			I don't like needles or giving blood
			I'm afraid that I could test positive
			I don't have time to be tested
			I'm not sure about how to get tested
			Other reason, please specify
		Which of the following health screening tests have you had in the last 12 months? (select all that apply)	Blood sugar test for diabetes		Checkbox, one-up vertical	Multi	N
			Cholesterol blood test
			Hepatitis C blood test
			HIV blood test
			none of the above
		How would you like to receive more information about health screening tests? (select all that apply)	Personal contact (in person or on phone) from my doctor or health care team		Checkbox, one-up vertical	Multi	N
			Email from my doctor or health care team
			Email from VA or My HealtheVet
			Information available on the My HealtheVet website
			Posters at a VA medical center
			Health fair or education session
			Handout given to me by my doctor or health care team
			Other, please specify	A
	A	Other method			Text area, no char limit		N
		Are you of Hispanic or Latino origin or descent?	Yes		Radio button, one-up vertical	Single	N
			No
		What is your race?	American Indian or Alaska Native		Radio button, one-up vertical	Single	N
			Asian
			Black or African American
			Native Hawaiian or Other Pacific Islander
			White (Caucasian)
			Other, please specify	A
	A	Other race			Text area, no char limit		N
		Which of the following best describes the highest level of education you have completed?	High school graduate		Radio button, one-up vertical	Single	N
			Some college or vocational school
			Current college or graduate student
			College graduate
			Some postgraduate school
			Graduate or professional degree

---

Sheet 30: Custom Qsts (7-22-2008)

Model Instance Name: VA - My HealtheVet

red & strike-through: DELETE

MID:

underlined & italicized: RE-ORDER

pink: ADDITION

Date:

3/1/2008

blue + -->: REWORDING

violet (bold): SKIP-LOGIC

MID: CUSTOM QUESTION LIST

QID

Skip Logic Label

Question Text

Answer Choices (limited to 50 characters)

Type (select from list)

Single or Multi

Required Y/N

ALM0169

How frequently do you visit the My HealtheVet web site?

First time

Dropdown (Select-one)

Single

Y

Types

Daily

Open-ended

More than once a day

Text Field – limited to 100 characters

About once a week

About once a month

About every 3 months

Text Area – no character limit

About every 6 months

Dropdown (Select-one)

Less than every 6 months

Radio Button One Up Vertical

RJB00080

Please rate your ability in using the Internet:

Beginner or novice (just starting/don't use Internet much)

Dropdown (Select-one)

Single

Y

Radio Button Two Up Vertical

Intermediate (use the Internet for a few things)

Radio Button Three Up Vertical

Advanced (frequently use Internet & search for information)

Radio Button Scale Has Don’t Know

ALM0170

Which of the following best describes you?

Veteran

Check-boxes

Multi

Y

Check-boxes

Family member of a veteran

Veteran service organization

News media

General public

VA employee

Federal government employee

State/local government employee

Other role

RJB00048

Please indicate your military period(s) of service:

Global War on Terror (OEF/OIF)

Check-boxes

Multi

Y

Desert Shield/Desert Storm

Vietnam War

Korean War

World War II

Peacetime Service

Other

Not Applicable

RJB00022

What were you trying to accomplish today in My HealtheVet? (please select all that apply)

Enter/keep track of personal information (My Caregivers, etc.)

Check-boxes

Multi

Y

Enter/keep track of personal health care information (blood pressure, blood sugar, etc.)

Look up information about a medication

Request a prescription refill

Access prescription history from my VA medical record

Find a VA health care facility

Research a health condition

Find information about VA Benefits

Other (please specify)

ALM0172

Did you accomplish what you wanted to in My HealtheVet?

Yes

Dropdown (Select-one)

Single

Y

No

Partially

Not finished yet

RJB00068

If you did not accomplish what you wanted to, what will you do next?

Continue looking on My HealtheVet

Radio Button One Up Vertical

Single

Y

Come back to My HealtheVet later

E-mail the Veterans Health Administration

Call the Veterans Health Administration

Look elsewhere online

Give up

Other

RJB00024

What additional services would you like to see on My HealtheVet? (please select all that apply)

Schedule or change my appointments

Check-boxes

Multi

Y

Advance check in for my VA clinic visits

Online, secure communication with my doctor

Look at information in my VA medical record

Share information I have stored in My HealtheVet with other people (e.g., family or doctor)

Reminders of preventive care I need (e.g., shots, cancer screening)

Checking that different medications I take are safe when used together

Educational programs

Monthly email newsletter

Notification of new content/features on the site

Information about the quality of VA health care

Advanced directive (e.g. living will, durable power of attorney for health care)

Other (please specify):

JIC00167

Have you prepared a document (e.g., advance directive, living will, durable power of attorney for health care) to help your loved ones and health care providers make medical decisions if you ever become too sick to communicate your wishes?

Yes (Go to A)

Radio Button One Up Vertical

Single

Y

No

JIC00168

A

If yes, what type of document(s) have you prepared?

Non-VA advance directive or living will

Check-boxes

Multi

Y

VA Living Will (a document that describes your preferences and/or values)

VA Durable Power of Attorney for Health Care (a document that designates your preferred decision maker)

Don't Know

Other (please specify):

RJB00070

Please describe your experience with navigation on this web site.

I had no difficulty navigating on this site

Check-boxes

Multi

Y

Too many buttons or links to other places

Links did not take me where I expected

I experienced links that went nowhere, error messages, or other technical difficulties

I was able to find general information, but could not find the specific content that I needed

Other navigational issue (please specify):

RJB00071

Did you use the web site's search feature today?

Yes (Go to B)

Dropdown (Select-one)

Single

Y

No (Go to A)

JIC00265

A

Why did you not use the search feature?

Prefer other method of navigation

Check-boxes

Multi

Y

Tried to use search but was unsuccessful

Did not need search, found information quickly

Other (please specify)

JIC00176

B

Please describe your experience with the site's search feature.

I had no difficulty using the search feature on this site

Check-boxes

Multi

Y

Could not tell what information the search results would take me to

Too many results

Too few results

Returned no results/received error message

Results were not related to what I was looking for

Other search issue (please specify):

RJB00026

Are you a registered user on the MyHealtheVet web site?

Yes

Dropdown (Select-one)

Single

Y

No

Not sure

RJB00027

Have you visited your VA Facility in person to show your ID and be "in-person authenticated" (IPA) for My HealtheVet?

Yes

Dropdown (Select-one)

Single

Y

No

Not sure

Not applicable

ALM0173

What is the main improvement that you would suggest for the My HealtheVet web site?

Open-ended

Single

N

JIC00268

Did you use a VA medical facility or service for any of your health care needs in the last 12 months?

Yes

Dropdown (Select-one)

Single

Y

No

JIC00269

In the last 12 months, where did you go for most of your routine outpatient care? (choose one that best fits your answer)

VA hospital or clinic

Dropdown (Select-one)

Single

Y

A non-VA hospital or clinic

Did not receive routine care or services in the past year

Don't know

JIC00270

If you have used urgent care or the emergency room in the last 12 months, where do you typically go? (choose one that best fits your answer)

A VA hospital or clinic

Dropdown (Select-one)

Single

Y

A non-VA hospital or clinic

Did not use urgent care or an emergency room in the past year

Don't know

JIC00170

Do you use a mobile phone?

Yes (Go to A)

Dropdown (Select-one)

Single

Y

No

JIC00171

A

Which mobile phone features do you use?

Phone calls

Check-boxes

Multi

Y

Text messaging

Access the Internet

Built-in Camera

Games

Other (please specify)

RJB00025

What is your age range?

Under 20

Dropdown (Select-one)

Single

N

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85 or older

JIC00267

What is your gender?

Male

Dropdown (Select-one)

Single

N

Female

JIC00178

In general, how would you rate your overall health?

Excellent

Dropdown (Select-one)

Single

Y

Very Good

Good

Fair

Poor

ALM0032

In which state do you reside?

List of states

Dropdown (Select-one)

Single

N

Canada

I live elsewhere