Promoting Patient Engagement in Clinical Preventive Services

Attachment A:

Promoting Patient Engagement in Clinical Preventive Services: Evaluating the Use of healthfinder – Patient Survey

OMB Control Number: 0990-0281

Research Instrument

February 2, 2018

Submitted to:

Sherrette Funn

Office of the Chief Information Officer

U.S. Department of Health and Human Services

Submitted by:

Linda M. Harris, PhD

Director, Division of Health Communication and eHealth

Office of Disease Prevention and Health Promotion

U.S. Department of Health and Human Services

Patient Survey

Overview: Total time — 5 minutes

We are asking for your participation in a research study. The purpose of the study is to understand your interactions with your clinician. The results of this study may help clarify whether providing community data will influence the delivery of primary care; however, there may not be any direct benefit to you.

If you decide to participate, please complete the accompanying survey. The survey takes five to eight minutes to complete. Researchers at Virginia Commonwealth University will then review it.

The primary risk of participation is breach of confidentiality; however, your individual responses will not be shared with others outside of the research team and your clinician. In publications and presentations, we will not use your name and will only report on aggregate results.

Participation in this study is voluntary. Your responses and your decision not to participate will not affect your access to care. After reading this consent form, you will have 30 minutes to make a decision regarding participation.

Your refusal to participate will involve no penalty or loss of benefits to which the subject is otherwise entitled, and the subject may discontinue participation at any time without penalty or loss of benefits to which the subject is otherwise entitled. The alternative to participation is to not participate.

Your clinician will review your responses. Some of these questions are sensitive in nature; therefore, please feel free to skip any questions you are uncomfortable answering. When you are done with the survey, please hand it back to the nursing staff.

If you are willing to participate, please complete this assessment. Thank you.

[Note: The 1^st set of questions – on pages 2 to 4 – are for female patients; the 2^nd set of questions – on pages 5 to 7 – are for male patients.]

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0281. The time required to complete this information collection is estimated to average 8 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer