Form 957 2015 957 Questionnaire Relaunch Updates Dec 2015 Final 1

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Overview

New 2015 Model
Current CQs

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Sheet 1: New 2015 Model

	Model Instance Name:
	HHS OCR
	MID:	doQhU1ZZoUowo8IpohgEJg==
	Date:	8/1/2015
	Model questions utilize the ACSI methodology to determine scores and impacts
```	Label	Element Questions		CUSTOMER SATISFACTION		FUTURE BEHAVIORS
		Look and Feel (1=Poor, 10=Excellent, Don't Know)		Satisfaction		Return (1=Very Unlikely, 10=Very Likely)
1	Look and Feel - Appeal	Please rate the visual appeal of this site.	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	Look and Feel - Balance	Please rate the balance of graphics and text on this site.	17	How well does this site meet your expectations? (1=Falls Short, 10=Exceeds)		Recommend (1=Very Unlikely, 10=Very Likely)
3	Look and Feel - Readability	Please rate the readability of the pages on this site.	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	Site Performance - Loading	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 from Health and Human Services Office for Civil Rights?
5	Site Performance - Consistency	Please rate the consistency of speed from page to page on this site.				Trust (1=Strongly Disagree, 10=Strongly Agree)
6	Site Performance - Completeness	Please rate how completely the page content loads on this site.			22	I can count on this Agency to act in my best interests.
		Navigation (1=Poor, 10=Excellent, Don't Know)			23	I consider this Agency to be trustworthy.
7	Navigation - Organized	Please rate how well this site is organized.				This Agency can be trusted to do what is right.
8	Navigation - Options	Please rate the options available for navigating this site.
9	Navigation - Layout	Please rate how well the site layout helps you find what you need.
		Information Browsing (1=Poor, 10=Excellent, Don't Know)
10	Information Browsing - Sort	Please rate the ability to sort information by criteria that are important to you on this site.
11	Information Browsing - Narrow	Please rate the ability to narrow choices to find the information you are looking for on this site.
12	Information Browsing - Features	Please rate how well the features on the site help you find the information you need.
		Site Information (1=Poor, 10=Excellent, Don't Know)
13	Site Information - Thoroughness	Please rate the thoroughness of information provided on this site.
14	Site Information - Understandable	Please rate how understandable this site’s information is.
15	Site Information - Answers	Please rate how well the site’s information provides answers to your questions.

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Sheet 2: Current CQs

Model Instance Name				red & strike-through: DELETE
HHS OCR				underlined & italicized: RE-ORDER
MID: doQhU1ZZoUowo8IpohgEJg==				pink: ADDITION
Date:	8/1/2015			blue + -->: REWORDING
HHS OCR CUSTOM QUESTION LIST
QID	Skip Logic Label	Question Text	AnswerIDs (DOT)	Answer Choices (limited to 50 characters)	Skip to	Type (select from list)	Single or Multi	Required Y/N	Special Instructions	CQ Label
SAC4713		How frequently do you visit this site?	SAC4713A001	This is my first time visiting the site		Radio button, one-up vertical	Single	Y		Frequency of Visit
			SAC4713A002	Daily	A
			SAC4713A003	About once a week	A
			SAC4713A004	About once a month	A
			SAC4713A005	Every few months	A
			SAC4713A006	Every 6 months or less often	A
	A	Did you notice any changes to the website during your visit today?		Yes	B	Radio button, one-up vertical	Single	Y	Skip Logic Group	Notice Changes
				No, I did not notice any changes
				Not sure
	B	How does the new website compare to the previous design?		Better than the previous website	C	Radio button, one-up vertical	Single	Y	Skip Logic Group	Website compare
				Same as the previous website
				Worse than the previous website	D
	C	Please tell us why you feel the new design is better than the previous website.				Text area, no char limit		N	Skip Logic Group	OE_new desn better
	D	Please tell us why you feel the new design is worse than the previous website.				Text area, no char limit		N	Skip Logic Group	OE_new desn worse
SAC4714		What best describes your role in visiting the site today?	SAC4714A001	General Public		Radio button, one-up vertical	Single	Y	Skip Logic Group	Primary Role
			SAC4714A002	Health Care Professional
			SAC4714A003	Human Services Professional
			SAC4714A004	HIPAA Covered Health Care Provider (health care provider that conducts certain transactions electronically)
			SAC4714A005	Health Care Clearinghouse
			SAC4714A006	Health Plan Provider(Health insurance companies, HMOs, Company health plans, Government programs that pay for health care, such as Medicare, Medicaid, and the military and veterans health care programs)
			SAC4714A007	HIPAA Business Associate
			SAC4714A008	Federal Government
			SAC4714A009	State/Local/Tribal Government
			SAC4714A010	Consultant/Legal
			SAC4714A011	HHS Employee
			SAC4714A012	Community Based Organization/Non Profit
			SAC4714A013	Advocacy Group
			SAC4714A014	Journalist/Media
			SAC4714A015	Researcher
			SAC4714A016	Educator
				Student, including research for an assignment
			SAC4714A017	Other, please specify	A
SAC4715	A	What best describes your role in visiting the site today?				Text area, no char limit		N	Skip Logic Group	OE_Primary Role
SAC4716		Please select your primary reason for visiting the site today? (Please select all that apply).	SAC4716A001	Information on Civil Rights	A,CR1, CR2	Checkbox, one-up vertical	Single	Y	Skip Logic Group	Primary Reason
			SAC4716A002	Information on Health Information Privacy	B, H1,H2
				Omnibus HIPAA Rule
			SAC4716A003	File a Complaint	C,D,CO1, CO2
			SAC4716A004	Information on how to file a Complaint	D, CO1, CO2
				HIPAA Audit Protocol
			SAC4716A005	Press Releases/News
			SAC4716A006	Training Materials	E
				Research
			SAC4716A007	Just Browsing
			SAC4716A008	Sign up for Listserv
			SAC4716A009	Other, please specify	Z
SAC4717	Z	Please describe your primary reason for visiting the site today.				Text area, no char limit		N	Skip Logic Group	OE_Primary Reason
SAC4718	A	Please tell us what Civil Rights Information you were looking for today?	SAC4718A001	General Civil Rights Information		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	Civil Rights Info
			SAC4718A002	Race, Color and National Origin Discrimination
			SAC4718A003	Language Access/L.E.P
			SAC4718A004	Disability Discrimination
			SAC4718A005	Olmstead
			SAC4718A006	Age Discrimination
			SAC4718A007	Enforcement Activities
			SAC4718A008	Hill-Burton Act
			SAC4718A009	Section 1557 of the Affordable Care Act
			SAC4718A010	Medicare Part A Certification
			SAC4718A011	Federal Health Care Conscience Protection Statues
			SAC4718A012	Civil Rights Fact Sheet
			SAC4718A013	Other, please specify	AA
SAC4719	AA	Please tell us specifically what Civil Rights Information you were looking for today.				Text area, no char limit		N	Skip Logic Group	OE_Other Civil Rights Info
SAC4720	B	Please tell us what Health Information Privacy Information you were looking for today?	SAC4720A001	General Health Information Privacy Information		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	Health Information
			SAC4720A002	HIPAA Privacy Rule
			SAC4720A003	HIPAA Security Rule
			SAC4720A004	Breach Notification Rule
			SAC4720A005	Patient Safety and Quality Improvement Act of 2005 (PSQIA)
				Model Business Associate Agreement
			SAC4720A006	Audit Program Information
			SAC4720A007	Information for Covered Entities
			SAC4720A008	Information for Consumers/Individuals
			SAC4720A009	States Attorneys General
			SAC4720A010	Enforcement Activities
			SAC4720A011	Other, please specify	BB
SAC4721	BB	Please tell us specifically what Health Information Privacy Information you were looking for today.				Text area, no char limit		N	Skip Logic Group	OE_Other Health Info
SAC4722	C	Please tell us what type of complaint you were looking to file	SAC4722A001	Civil Rights Discrimination Complaint		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	Civil Rights Complaint Type Info
			SAC4722A002	HIPAA Privacy Rule Complaint
			SAC4722A003	HIPAA Security Rule Complaint
			SAC4722A004	Patient Safety Confidentiality Complaint (PSQIA)
			SAC4722A005	Federal Health Care Conscience Protection Statutes
			SAC4722A006	Other, please specify	CC
SAC4723	CC	Please tell us what other civil rights discrimination complaint you were looking to file.				Text area, no char limit		N	Skip Logic Group	OE_Other CR Complaint Info
SAC4724	D	Did you download information on how to file a complaint?	SAC4724A001	Yes	DD	Radio button, one-up vertical	Single	N	Skip Logic Group	Download how to File
			SAC4724A002	No
			SAC4724A003	I don’t know
SAC4725	DD	Was this information useful?	SAC4725A001	Yes		Radio button, one-up vertical	Single	N	Skip Logic Group	Use of How to file complaint
			SAC4725A002	No
			SAC4725A003	I don’t know
SAC4726	E	Please tell us what training materials you were looking for.				Text area, no char limit		N	Skip Logic Group	OE_Other CR Complaint Info
	H1	How did you find the HIPAA - Health Information Privacy information?		Navigated from HHS.gov homepage
				Searched using HHS.gov homepage search
				Searched using an outside search engine (e.g., Google, Bing, Yahoo, etc.)
				Other	X
				Don't know		Text area, no char limit
	X	What other method did you use to find the HIPAA - Health Information Privacy information?
	H2	How easy was it to find the HIPAA - Health Information Privacy information?		1 (Not very easy)
				2
				3
				4
				5
				6
				7
				8
				9
				10 (Very easy)
				Don't know
	CR1	How did you find the Civil Rights information?		Navigated from HHS.gov homepage
				Searched using HHS.gov homepage search
				Searched using an outside search engine (e.g., Google, Bing, Yahoo, etc.)
				Other	Y
				Don't know
	Y	What other method did you use to find the Civil Rights information?				Text area, no char limit
	CR2	How easy was it to find Civil Rights information?		1 (Not very easy)
				2
				3
				4
				5
				6
				7
				8
				9
				10 (Very easy)
				Don't know
	CO1	How did you find where to file a complaint or information on filing a complaint?		Navigated from HHS.gov homepage
				Searched using HHS.gov homepage search
				Searched using an outside search engine (e.g., Google, Bing, Yahoo, etc.)
				Other	Z
				Don't know
	Z	What other method did you use to find where to file a complaint or information on filing a complaint?				Text area, no char limit
	CO2	How easy was it to find where to file a complaint or information on filing a complaint?		1 (Not very easy)
				2
				3
				4
				5
				6
				7
				8
				9
				10 (Very easy)
				Don't know
ACQinh0019336		Did you visit the Audit Program section of the site today?		Yes	A	Radio button, one-up vertical		Y	Skip Logic Group	Audit Protocol Use
				No
				Don’t know
ACQinh0019337	A	Did you find what you were looking for using the Audit Program?		Yes		Radio button, one-up vertical		Y	Skip Logic Group	Audit Protocol Find
				No
ACQinh0019339		Did you use the one of Frequently Asked Questions portion of the site today?		Yes	A,B	Radio button, one-up vertical	Single	Y	Skip logic Group	FAQ use
				No
ACQinh0019340	A	Which FAQ section did you use today?		HIPAA
				Civil Rights
				I don't know/don't remember
ACQinh0019341	B	Did you find what you were looking for?		Yes
				No	BB
ACQinh0019342	BB	Please tell us what you could not find using the Frequently Asked questions today:				Text area, no char limit		N	Skip Logic Group	OE_FAQ Unable to find
ACQinh0023735		Which of the following sources primarily drove you to the site today?		Email from OCR				Y	Skip Logic Group	Learn about Site
				Internet blogs or discussion forums
				Search engine results
				Blog or other Social Media (e.g. Facebook, Twitter)
				Word of mouth recommendation from someone I know
				TV, radio, newspaper, or magazine advertising
				Internet advertising
				Familiarity with OCR
				Don't know
				Other (please specify):	A
ACQinh0023736	A	Please tell us how you learned of this site:				Text area, no char limit		N		OE_Learn about Site
SAC4730		How did you look for information on the site today? (Please select all that apply.)	SAC4730A001	Search feature at top of page	A	Checkbox, one-up vertical	Multi	Y	Skip Logic Group	Navigation Tools
			SAC4730A002	Navigation tabs across the top of the page	C
			SAC4730A003	Navigation links along left side of page	C
			SAC4730A004	The links along the right side of the page	C
			SAC4730A005	The links in the body of the page	C
			SAC4730A006	Other, please specify	D
SAC4731	D	Other way I looked for information:				Text area, no char limit		N	Skip Logic Group	OE_Navigation
SAC4732	A	Please tell us about your experience with the site's search feature today. (Please select all that apply.)	SAC4732A001	Results were satisfactory (met my expectations)		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	Search Experience
			SAC4732A002	Results were not relevant	B
			SAC4732A003	Too many results	B
			SAC4732A004	Not enough results	B
			SAC4732A005	Returned NO results	B
			SAC4732A006	Received error message(s)	B
			SAC4732A007	Search speed was too slow	B
			SAC4732A008	I experienced a different search issue (please explain):	AA, B
SAC4733	AA	Please tell us what your search experience was today.				Text area, no char limit		N	Skip Logic Group	OE_Search
SAC4734	B	How can we make the search feature more useful to you?				Text area, no char limit		N	Skip Logic Group	OE_Search Improvement
SAC4735	C	What specific ways can we improve your experience navigating this site?				Text area, no char limit		N		OE_Improve Navigation
SAC4727		Did you find what you were looking for on the site today?	SAC4727A001	Yes		Radio button, one-up vertical	Single	Y	Skip Logic Group	Ability to Find
			SAC4727A002	No	A,B
SAC4728	A	Please tell us specifically what you couldn't find on the site today:				Text area, no char limit	Single	N	Skip Logic Group	OE_Ability to Find
SAC4729	B	Please tell us why you were not able to find what you were looking for. (Please select all that apply)	SAC4729A001	I could not access the information on site		Checkbox, one-up vertical	Multi	N	Skip Logic Group	Unable to Find
			SAC4729A002	The search results did not appear relevant
			SAC4729A003	The links did not take me where I wanted
			SAC4729A004	The labeling on lists didn't match what I was looking for
			SAC4729A005	How the information is organized on the site wasn't clear
			SAC4729A006	The navigation options were difficult to understand
			SAC4729A007	Other
ACQinh0023737		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
ACQinh0023738		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
ACQinh0023739		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
SAC4741		Please select the category that includes your age.	SAC4741A001	Under 18		Drop down, select one	Single	N		Age
			SAC4741A002	18-24
			SAC4741A003	25-34
			SAC4741A004	35-44
			SAC4741A005	45-54
			SAC4741A006	55-64
			SAC4741A007	65-74
			SAC4741A008	75 or older
			SAC4741A009	Prefer not to answer
SAC4742		What is your gender?	SAC4742A001	Male		Drop down, select one	Single	N		Gender
			SAC4742A002	Female
			SAC4742A003	Prefer not to answer
		Is English your primary language?		Yes		Radio button, one-up vertical	Single	N		Primary language
				No	A
	A	Did you call the 800 number to get translation assistance?		Yes		Radio button, one-up vertical	Single	Y		Translation usage
				No	B
	B	Were you aware that the Office of Civil Rights offered this service on the website?		Yes		Radio button, one-up vertical	Single	Y		Translation awareness
				No	C
	C	Now that you are aware of the translation service, how likely are you to use it during your next visit? (1-Very Unlikely, 5-Very Likely)		1- Very Unlikely		Checkbox, one-up vertical	Single	Y		Intent-Translation usage
				2- Somewhat Unlikely
				3- Not sure
				4- Somewhat Likely
				5- Very likely
SAC4743		If you could recommend one change to improve this site what would it be?				Text area, no char limit		N		OE_Improvement