Form 1125 2014 880 SAMHSA Store

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Overview

Model Qsts
Current Custom Qsts

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Sheet 1: Model Qsts

Model Instance Name:			red & strike-through: DELETE
SAMHSA Store V2			underlined & italicized: RE-ORDER
MID: AlJRpZ1w1xJYE9MMtg8JdA==			pink: ADDITION
Date:	7/16/2013		blue + -->: REWORDING
SAMHSA Store V2
Model questions utilize the ACSI methodology to determine scores and impacts
	ELEMENTS (drivers of satisfaction)		CUSTOMER SATISFACTION		FUTURE BEHAVIORS
	Navigation (1=Poor, 10=Excellent, Don't Know)		Satisfaction		Return (1=Very Unlikely, 10=Very Likely)
1	Please rate how well the site is organized.	16	What is your overall satisfaction with this site? (1=Very Dissatisfied, 10=Very Satisfied)	19	How likely are you to return to this site?
2	Please rate the options available for navigating this site.	17	How well does this site meet your expectations? (1=Falls Short, 10=Exceeds)		Recommend (1=Very Unlikely, 10=Very Likely)
3	Please rate how well the site layout helps you find what you are looking for.	18	How does this site compare to your idea of an ideal website? (1=Not Very Close, 10=Very Close)	20	How likely are you to recommend this site to someone else?
	Site Performance (1=Poor, 10=Excellent, Don't Know)				Primary Resource (1=Very Unlikely, 10=Very Likely)
4	Please rate how quickly pages load on this site.			21	How likely are you to use this site as your primary resource for obtaining information and ordering publications from this agency?
5	Please rate the consistency of speed from page to page on this site.
6	Please rate the ability to load pages without getting error messages on this site.
	Site Information (1=Poor, 10=Excellent, Don't Know)
7	Please rate the thoroughness of information provided on this site.
8	Please rate how understandable this site’s information is.
9	Please rate how well the site’s information provides answers to your questions.
	Look and Feel (1=Poor, 10=Excellent, Don't Know)
10	Please rate the visual appeal of this site.
11	Please rate the balance of graphics and text on this site.
12	Please rate the readability of the pages on this site.
	Information Browsing (1=Poor, 10=Excellent, Don't Know)
13	Please rate the ability to sort information by criteria that are important to you on this site.
14	Please rate the ability to narrow choices to find the information you are looking for on this site.
15	Please rate how well the features on the site help you find the information you are looking for.

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Sheet 2: Current Custom Qsts

Model Instance Name:			red & strike-through: DELETE
SAMHSA Store V2			underlined & italicized: RE-ORDER
MID: AlJRpZ1w1xJYE9MMtg8JdA==			pink: ADDITION
Date: 7/11/2013			blue + -->: REWORDING
SAMHSA Store V2 CUSTOM QUESTION LIST
QID (Group ID)	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	CQ Label
		How frequently do you visit the SAMHSA Store?	First time		Drop down, select one	S	Y		Frequency of visits
			Daily
			Weekly
			Monthly
			Every few months or less often
		What is your primary interest in substance abuse and mental health topics?	Personal	A1-A8	Drop down, select one	S	Y	Skip Logic Group	Primary interest
			Professional	B1-B10
	A1	For whom are you looking up information and resources?	Yourself		Radio button, one-up vertical	S	Y		Personal info for
			Family member
			Friend
	A2	What is the age of the person for whom you are seeking resources?	12 and under		Radio button, one-up vertical	S	Y		Personal age
			13 to 17
			18 to 24
			25 to 34
			35 to 44
			45 to 54
			55 to 64
			65 and older
	A3	Are you primarily looking for information on any of the following topics?	Treatment and recovery	A4	Radio button, one-up vertical	S	Y		Personal info topic
			Preventing substance abuse problems	A5
			Preventing mental illness/promoting mental wellness	A6
			Helping someone cope with and recover from a traumatic event	A7
			Other, please specify	A8
	A4	Please specify the topic of interest for treatment and recovery. (Check all that apply)	Options for paying for treatment		Checkbox, one-up vertical	M	Y		Personal treatment
			Understanding different types of treatment
			Identifying a treatment professional or facility
			Recovery support services (e.g., support groups)
			Information about specific substances of abuse
			Information about specific mental illnesses
	A5	Please specify the topic of interest for substance abuse prevention. (Check all that apply)	Alcohol		Checkbox, one-up vertical	M	Y		Personal SA prevention
			Illegal substances (e.g., marijuana, cocaine)
			Prescription drugs
			Tobacco
	A6	Please specify the topic of interest for preventing mental illness and promoting mental wellness. (Check all that apply)	Anger management		Checkbox, one-up vertical	M	Y		Personal MH illness
			Anxiety or depression
			Bullying prevention
			Eating disorders
			PTSD
			Schizophrenia
			Stress management
			Suicide prevention
	A7	Please specify the topic of interest for trauma recovery. (Check all that apply)	Death of a loved one		Checkbox, one-up vertical	M	Y		Personal trauma
			Physical or sexual abuse
			Natural disaster
			Mass violence
			Post-military deployment
	A8	Please specify other information looking for.			Text area, no char limit		N		Personal other info
	B1	What best describes your organization type?	Behavioral health treatment facility		Radio button, one-up vertical	S	Y		Organization type
			Other health care facility (e.g., primary care)
			Government office
			Nonprofit/community-based organization/coalition
			School/university
			Military/veterans group
			Criminal justice/courts
			Health insurer
			Human resources/employee assistance program
			Other
	B2	For whom are you primarily looking for information and resources?	Professional education for self/colleagues		Radio button, one-up vertical	S	Y		Professional info for
			Use with patients/clients
			Use within classroom/youth setting
			Public awareness campaign/event
			Other
	B3	Which of the following best describes the age of your patients, clients, or students?	12 and under		Radio button, one-up vertical	S	Y		Professional age
			13 to 17
			18 to 24
			25 to 34
			35 to 44
			45 to 54
			55 to 64
			65 and older
	B4	Were you primarily looking for information on any of the following topics?	Affordable Care Act (e.g., health reform, parity)	B5	Radio button, one-up vertical	S	Y		Professional info topic
			Treatment and recovery	B6
			Substance abuse prevention	B7
			Preventing mental illness/promoting mental wellness	B8
			Trauma	B9
			Other, please specify	B10
	B5	Please specify the topic of interest for Affordable Care Act. (Check all that apply)	Reimbursement for behavioral health services		Checkbox, one-up vertical	M	Y		Professional ACA
			Enrolling patients/clients in health insurance exchanges or Medicaid/Medicare
			Other
	B6	Please specify the topic of interest for treatment and recovery. (Check all that apply)	Patient/client educational materials		Checkbox, one-up vertical	M	Y		Professional treatment
			Evidence based practices
			Information for working with specific populations
			Information about specific substances of abuse
			Information about specific mental illnesses
	B7	Please specify the topic of interest for substance abuse prevention. (Check all that apply)	Alcohol		Checkbox, one-up vertical	M	Y		Professional SA prevention
			Illegal substances (e.g., marijuana, cocaine)
			Prescription drugs
			Tobacco
			Parenting/family resources
	B8	Please specify the topic of interest for preventing mental illness and promoting mental wellness. (Check all that apply)	Anger management		Checkbox, one-up vertical	M	Y		Professional MH illness
			Bullying prevention
			Eating disorders
			Mood disorders
			PTSD
			Schizophrenia
			Stress management
			Suicide prevention
			Parenting/family resources
	B9	Please specify the topic of interest for trauma. (Check all that apply)	Grief		Checkbox, one-up vertical	M	Y		Professional trauma
			Physical or sexual abuse
			Natural disaster
			Mass violence
			Post-military deployment
	B10	Please specify other information looking for.			Text area, no char limit		N		Professional other info
		Did you find what you were looking for?	Yes		Drop down, select one	S	Y		Find info
			No
			Partially
			Still looking
		How satisfied were you with the content available?	Very satisfied		Drop down, select one	S	Y	Skip Logic Group	Content satisfaction
			Somewhat satisfied
			No opinion
			Somewhat dissatisfied	A
			Very dissatisfied	A
	A	Please tell us how our products and resources could be improved.			Text area, no char limit		N		Improve products
		What services could this agency provide to better serve you?			Text area, no char limit		N		Other services wanted
		Please specify the types of electronic devices you use. (Check all that apply)	Desktop or laptop computer		Checkbox, one-up vertical	M	Y		Device type
			Tablet or e-reader (e.g., iPad, Kindle, Nook)
			Smartphone (e.g., iPhone or similar devices with web access)
			Cell phone
The following demographics questions are entirely optional and will be used for statistical purpose only.
		What is your gender?	Female		Drop down, select one	S	N		Gender
			Male
			Prefer not to respond
		Please select the category that includes your age.	17 and under		Drop down, select one	S	N		Age
			18 - 24
			25 - 34
			35 - 44
			45 - 54
			55 - 64
			65 and over
			Prefer not to respond
		Which of the following best describes the highest level of education you have completed?	Current middle or high school student		Drop down, select one	S	N		Education
			Did not complete high school
			High school graduate
			Some college/vocational school
			College graduate
			Some postgraduate school
			Graduate/professional degree
			MD/PhD
			Prefer not to respond
		What state do you live in?	Alabama		Drop down, select one	S	N		State
			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
			Prefer not to respond
		Are you living in a:	Urban area		Drop down, select one	S	N		Living area
			Rural area
			Don't know
		How do you describe your ethnicity?	Hispanic		Drop down, select one	S	N		Ethnicity
			Non-Hispanic
			Prefer not to respond
		How do you describe your race?	American Indian or Alaska Native		Drop down, select one	S	N		Race
			Asian or Pacific Islander
			African American or Black
			White
			Other
			Prefer not to respond