Form 1 Appendix A Provider Survey

Appendix A OMB#0925-0653, Exp. date: 4/2018

NINR SURVEY: Pediatric Palliative Care Provider Resources

Survey Introductory Paragraph

The National Institute of Nursing Research (NINR), part of the National Institutes of Health, is asking for feedback from health care providers who care for children with serious illnesses. NINR developed the Palliative Care: Conversations Matter^® campaign to increase awareness about pediatric palliative care. The campaign has materials for both providers and families. We would like to hear from you about how best to share the campaign information with fellow providers.

This survey does not collect or save any identifying information, so your answers are anonymous. It should take 5 minutes or less to complete. Please skip any question you do not wish to answer.

Thank you in advance for your help. Your feedback is very important to us and will help us make sure more providers know about the campaign.

If you would like to learn more about NINR or the campaign, please go to http://www.ninr.nih.gov/conversationsmatter.

1. Select the top three ways you get health information for your practice.

• From colleagues

• Print materials like books and brochures

• Correspondence from your hospital or clinic

• Correspondence from a professional association

• Medical journals

• Websites/online resources

• Conferences/workshops

• Message boards or online groups

• Social media like Facebook, Twitter, or YouTube

• TV, radio, or newspaper

• Pharmaceutical representatives

• Other: ___________________________________

2. How do you usually share health information with your colleagues?

• I tell them about it by phone

• I tell them about it in person

• I text or email information like articles and websites

• I give presentations/grand rounds

• I discuss information in chat rooms, on message boards, or online groups

• I share through social media

• Other: ____________________________________

• I do not usually share resources I find

3. How likely are you to use a toolkit to introduce Palliative Care: Conversations Matter® campaign materials to other providers? (The toolkit would include items such as PowerPoint slides, a workshop facilitator guide, and email invitation templates.)

• Extremely likely

• Very likely

• Somewhat likely

• Not very likely

• Not at all likely

4. Please select the top three ways you think NINR could best connect with health care providers to let them know about Palliative Care: Conversations Matter® campaign resources.

   • Personalized emails

   • Direct mail

   • Online ads on sites such as American Academy of Pediatrics (AAP) News, Hospital Pediatrics or other pediatric-focused websites/journals

   • Print ads in pediatric-focused medical journals

   • Webinars

   • Hospital seminars

   • Social media

   • Conferences

   • Other: ­­­­­­­­­­­­­­­________________________________

Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0653). Do not return the completed form to this address.

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