Fast Track Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

Fast Track Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

DCoEProductFeedbackQuestion Bank_9DEC15.XLSX

Fast Track Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

OMB: 0704-0552

Document [xlsx]
Download: xlsx | pdf

Overview

Introduction
Question Bank
Data Dictionary


Sheet 1: Introduction

Overview: The DCoE Product Question Bank provides a variety of questions designed to gather feedback regarding DCoE products to improve product content, format, accessibility, reach, impact, ease of use, and relevance to stakeholders’ needs. The results of the information collection will guide DCoE’s efforts to meet the important goal of ensuring consumers are aware of DCoE products and services and to improve them in a manner that will increase utilization.

General Process
DCoE staff will:
1) Select the mandatory question ('How likely is that you would recommend this product or service to a friend or colleague?') from the bank.
2) Select additional relevant questions from the bank and when applicable, customize the question value as indicated by <text> to reference a specific product or training. For example: 'Rate how much you agree or disagree about using this <product/presentation/training>' may be modified to read 'Rate how much you agree or disagree about using the Family Resiliency Kit.'
3) Organize the questions in a logical sequence and test the collection instrument internally for appropriateness in content and length.
4) Finalize the draft collection instrument to include the introduction, instructional text, etc. in a DoD approved web-based survey tool. If open-ended / free text questions are used in the instrument, include the following instruction in the survey introduction, 'Please do not provide any Personally Identifiable Information (PII).'
5) Develop the Office of Management and Budget 'one pager' and related paperwork for submission through the OMB Regular or Fast Track generic clearance process.
6) Upon receipt of approval, update the collection instrument as needed and add the appropriate OMB Control Number. When used for DoD internal collections as well, include the related DoD Registration Control Symbol (RCS) in the top right corner below the OMB Control Number.
7) Execute the collection, monitor results and track respondent burden accordingly.


Sheet 2: Question Bank

Question No. Question Focus Target Audience Question Introduction
(where applicable)
Question Response Options Note to Question Bank User
REQUIRED QUESTION FOR ALL INSTRUMENTS Product Referral Both Provider and Non-provider
How likely is that you would recommend this product or service to a friend or colleague? Not at all likely
Slightly likely
Somewhat likely
Very likely
Extremely likely
REQUIRED QUESTION FOR ALL INSTRUMENTS
1 Product Utilization Provider
At what frequency would you like to receive information related to upcoming DCoE webinars and/or products? (e.g., daily, weekly, monthly, quarterly) Daily
A few times a week
Weekly
Monthly
Quarterly

2 Demographic Both Provider and Non-provider
What is your gender? Female
Male

3 Demographic Both Provider and Non-provider
Are you Spanish/Hispanic/Latino?
No, not Spanish/Hispanic/Latino
Yes, Mexican, Mexican-American, Chicano, Puerto Rican, Cuban, or other Spanish/Hispanic/Latino

4 Demographic Both Provider and Non-provider
What is your race? (Select one or more.) American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

5 Demographic Both Provider and Non-provider
What is your age? Less than 17 years old
17-24 years old
25-34 years old
35-44 years old
45-54 years old
55-64 years old
65-74 years old
75 years or older

6 Demographic Both Provider and Non-provider
What is your marital status?
Married
Separated
Divorced
Widowed
Never Married

7 Demographic Both Provider and Non-provider
How many children do you have? I do not have any children
1
2
3
4
5+

8 Demographic Both Provider and Non-provider
How old are your children? Select all that apply. Younger than 5
5-10
11-15
16-20
21-25
Older than 25
N/A

9 Demographic Both Provider and Non-provider
What is the highest degree or level of school you have completed? No high school diploma
High school diploma or GED
Some college
Associates degree
Bachelor's degree
Master's degree
Professional degree (e.g., JD, MD)
Doctorate degree (e.g., PhD, EdD)

10 Demographic Both Provider and Non-provider
What was your total household income last year? Less than $24,999
$25,000 to $49,999
$50,000 to $99,999
$100,000 to $149,999
$150,000 to $199,999
$200,000 or more

11 Demographic Both Provider and Non-provider
What is your professional status? Active Duty Military
Government Contractor
Government Civilian
National Guard / Reserves
Non-government Civilian
Retiree
Other (Please specify) ____
If question is selected, please include the following text in the instrument instructions: "Please do not provide any Personally Identifiable Information (PII)."
12 Demographic Both Provider and Non-provider
What is your military status? Active Duty
National Guardsman / Reservist
Veteran
Not applicable

13 Demographic Both Provider and Non-provider
What is your current pay grade?
E1-E4 (Junior Enlisted)
E5-E6 (Junior NCOs)
E7-E9 (Senior NCOs)
W1-W5 (Warrant Officers)
O1-O3 (Junior Officers)
O4-O6 (Senior Officers)
O7 or above (General/Flag Officers)
Not Applicable

14 Demographic Non-provider
Please select the military organization you are / have been a member. Select all that apply. Army
Navy
Marines
Air Force
Coast Guard
US Public Health Service
Other (Please specify) ____
If question is selected, please include the following text in the instrument instructions: "Please do not provide any Personally Identifiable Information (PII)."
15 Demographic Non-provider
How long have you been in the military? <1 year
1-5 years
6-10 years
11-15 years
16-20 years
20+ years
N/A

16 Demographic Non-provider
How many times have you been deployed? I have never been deployed
1
2
3
4
5+

17 Demographic Non-provider
How recent was your last deployment? Less then 1 month ago
1-6 months ago
7-11 months ago
1-5 years ago
6-10 years ago
10+ years ago
Not applicable

18 Demographic Non-provider
How many times have you deployed to combat zones? I have never been deployed to a combat zone
1
2
3
4
5+

19 Demographic Non-provider
To what combat zone were you deployed? Select all that apply. Operation Desert Storm
Operation Iraqi Freedom/ New Dawn
Operation Enduring Freedom
Kosovo
Vietnam
Other (Somalia, Lebanon, Korea, WW2, etc.,) Please describe.
If question is selected, please include the following text in the instrument instructions: "Please do not provide any Personally Identifiable Information (PII)." Note: This question would only be asked if Q21 was asked as well.
20 Demographic Non-provider
Please select your primary role:
Service member
Family/friend of service member
Veteran
Healthcare provider
Mental healthcare provider
Caregiver
Researcher/academia
Chaplain
Other (Please specify) ____
If question is selected, please include the following text in the instrument instructions: "Please do not provide any Personally Identifiable Information (PII)."
21 Demographic Non-provider
What is your relationship to the Service member? Self
Spouse/Partner
Parent/Sibling
Child
No Relationship
Other (Please specify) ____
If question is selected, please include the following text in the instrument instructions: "Please do not provide any Personally Identifiable Information (PII)."
22 Demographic Non-provider
Do you work in the Military Health System? Yes
No

23 Demographic Non-provider
Are you currently seeing a mental health professional?

Yes
No

24 Demographic Provider
Have you seen a mental health professional while serving in the military? Yes
No

25 Demographic Provider
If you are a TRICARE provider, which region? North
South
West
OCONUS (International SOS)
I am not a TRICARE provider

26 Demographic Provider
What is your primary role as a provider? <Insert appropriate professional role>
<Insert appropriate professional role>
<Insert appropriate professional role>
Other (Please specify) ____
If question is selected, please include the following text in the instrument instructions: "Please do not provide any Personally Identifiable Information (PII)."
27 Demographic Provider
In what settings do you provide counseling services ? Select all that apply.
Inpatient Behavioral Health
Inpatient Settings (Other)
Intensive Outpatient Settings
Specialty Behavioral Health (Outpatient)
Tele-behavioral Health / Web-based / Online Services
Other (Please specify) ____
If question is selected, please include the following text in the instrument instructions: "Please do not provide any Personally Identifiable Information (PII)."
28 Demographic Provider
As a behavioral health counselor, what is your primary focus? Select all that apply. Addiction
Combat Stress
Mental Health
Military Life
Marital and Family Life
Rehabilitation and Disability
Trauma and Disaster
Other (Please specify) ____
I am not a behavioral health counselor
If question is selected, please include the following text in the instrument instructions: "Please do not provide any Personally Identifiable Information (PII)."
29 Demographic Provider
What type of health services do you provide? Select all that apply. Individual therapy
Family therapy
Marriage and Couples Therapy
Group therapy
Care management
Psychopharmacology
Other
If question is selected, please include the following text in the instrument instructions: "Please do not provide any Personally Identifiable Information (PII)."
30 Demographic Provider
What is your primary patient population? Active Duty
Civilian
Couples/families
Dependents - children only
Dependents - spouses only
Guard / Reserve
Veteran
Other (please specify)
If question is selected, please include the following text in the instrument instructions: "Please do not provide any Personally Identifiable Information (PII)."
31 Demographic Provider
How many years of clinical experience do you have since finishing your professional degree? < 1 year
1-5 years
6-10 years
11-15 years
16-20 years
20+ years

32 Demographic Provider
Roughly how many patients are you currently responsible for in your clinic (i.e., panel size/caseload)? 0-25
25-49
50-69
75-99
100 or more

33 Demographic Provider
On average, how many patient sessions do you have per week? Free text If question is selected, please include the following text in the instrument instructions: "Please do not provide any Personally Identifiable Information (PII)."
34 Demographic Provider
On average, how many direct patient care hours do you complete a week? Free text If question is selected, please include the following text in the instrument instructions: "Please do not provide any Personally Identifiable Information (PII)."
35 Product Effectiveness Both Provider and Non-provider Please select the option that best describes your opinion with the content of the <product/presentation/training>: I learned new information I did not already know Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

36 Product Effectiveness Both Provider and Non-provider Rate how much you agree or disagree with the content of the <product/presentation/training>: The content is engaging and holds my interest. Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

37 Product Effectiveness Both Provider and Non-provider
How would you rate your knowledge of the topic after using this <product/presentation/training>? Well above average
Above average
Average
Below average
Well below average
To ask about knowledge before use of the product, use question 131.
38 Product Effectiveness Both Provider and Non-provider Rate how much you agree or disagree about using this product: I found the <product/presentation/training> very helpful. Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

39 Product Effectiveness Both Provider and Non-provider Rate how much you agree or disagree about using this <product/presentation/training>: This product will help my spouse or a family member with a problem he/she is having. Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

40 Product Effectiveness Both Provider and Non-provider Rate how much you agree or disagree about using this <product/presentation/training>: This product increased my knowledge about the subject matter. Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

41 Product Effectiveness Both Provider and Non-provider Rate how much you agree or disagree about using this <product/presentation/training>: This product increased my skills in this subject area. Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

42 Product Effectiveness Non-provider Rate how much you agree or disagree with the content of the <product/presentation/training>: The content covered information I need since <I/my spouse/family member> returned from deployment. Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

43 Product Effectiveness Non-provider Rate how much you agree or disagree with the content of the <product/presentation/training>: The content covered information that my family needs since <I/my spouse/family> member returned from deployment. Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

44 Product Effectiveness Non-provider Rate how much you agree or disagree about using this <product/presentation/training>: This product changed my attitude about the subject matter Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

45 Product Effectiveness Provider Rate how much you agree or disagree with the following product features: My expectations for this <product/presentation/training> were met.
Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

46 Product Effectiveness Provider Rate how much you agree or disagree with the following product features: I was able to learn most of the skills covered in this <presentation/training>
Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

47 Product Effectiveness Provider Rate how much you agree or disagree with the following product features: Other, please specify ___ Free text If question is selected, please include the following text in the instrument instructions: "Please do not provide any Personally Identifiable Information (PII)."
48 Product Effectiveness Provider
Please rate your overall level of satisfaction with the <product/presentation/training>. Very satisfied
Satisfied
Neutral
Dissatisfied
Very dissatisfied

49 Product Effectiveness Provider
This product made a significant and positive impact on the outcome of <your friend/family member/patient> treatment . Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

50 Product Effectiveness Provider
How would you rate the usefulness of this product on the intended user (e.g., provider, patient, family)? Not useful at all
Rarely or barely useful
Somewhat useful
Moderately useful
Very useful

51 Product Impact Both Provider and Non-provider Rate how much you agree or disagree about how this <product/presentation/training> changed the way you: Interact with your <friend/patient> Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

52 Product Impact Both Provider and Non-provider Rate how much you agree or disagree about how this <product/presentation/training> changed the way you: Respond to the topic/situation Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

53 Product Impact Both Provider and Non-provider Rate how much you agree or disagree about how this <product/presentation/training> changed the way you: View the issue/topic at hand Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

54 Product Impact Both Provider and Non-provider The <product/presentation/training> changed the way you: Physically examine patients. Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

55 Product Impact Both Provider and Non-provider The <product/presentation/training> changed the way you: Refer patients to specialty care Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

56 Product Impact Both Provider and Non-provider The <product/presentation/training> changed the way you: Determine which treatments you recommend to patients Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

57 Product Impact Both Provider and Non-provider The <product/presentation/training> changed the way you: Educate patients Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

58 Product Impact Both Provider and Non-provider The <product/presentation/training> changed the way you: Collaborate with other providers Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

59 Product Impact Both Provider and Non-provider The <product/presentation/training> changed the way you: No impact on your practice. Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

60 Product Impact Both Provider and Non-provider
As a result of using the product, the amount of time I spend with patients. Decreased
Increased
Did not change

61 Product Impact Non-provider Rate how much you agree or disagree about using this <product/presentation/training>: I found the product has motivated me to seek counseling.
Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

62 Product Impact Non-provider Rate how much you agree or disagree about how this <product/presentation/training> changed the way you: Other, please specify __ Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

63 Product Impact Provider Rate how much you agree or disagree about how this <product/presentation/training> changed the way you: Access resources. Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

64 Product Impact Provider Rate how much you agree or disagree about how this <product/presentation/training> changed the way you: Care for <your friend/family member/patient>. Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

65 Product Impact Provider Rate how much you agree or disagree about how this <product/presentation/training> changed the way you: Diagnose patients. Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

66 Product Impact Provider Rate how much you agree or disagree about how this <product/presentation/training> changed the way you: Evaluate patients. Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

67 Product Impact Provider Rate how much you agree or disagree about how this <product/presentation/training> changed the way you: Interview patients. Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

68 Product Improvement Both Provider and Non-provider Please select the option that best describes your opinion with the content of the <product/presentation/training>: Content is accurate. Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

69 Product Improvement Both Provider and Non-provider Rate how much you agree or disagree with the content of the <product/presentation/training>: The content is based on the best evidence available. Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

70 Product Improvement Both Provider and Non-provider Rate how much you agree or disagree with the following product features: The product content is easy to understand. Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

71 Product Improvement Both Provider and Non-provider Rate how much you agree or disagree with the following product features: The product is visually appealing Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

72 Product Improvement Both Provider and Non-provider Please select the option that best describes your opinion with the content of the <product/presentation/training>: Content is consistent. Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

73 Product Improvement Both Provider and Non-provider Please select the option that best describes your opinion with the content of the <product/presentation/training>: Content is up-to-date. Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

74 Product Improvement Both Provider and Non-provider Rate how much you agree or disagree with the content of the <product/presentation/training>: The correct depth of information is provided; it's just the right amount of detail. Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

75 Product Improvement Both Provider and Non-provider Rate how much you agree or disagree with the following product features: The product is logically organized. Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

76 Product Improvement Both Provider and Non-provider Rate how much you agree or disagree with the following product features: It is easy to use the product. Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

77 Product Improvement Both Provider and Non-provider Rate how much you agree or disagree with the following product features: The product is formatted for easy reference.
Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

78 Product Improvement Both Provider and Non-provider
What changes would you recommend to make this product more effective? Free text If question is selected, please include the following text in the instrument instructions: "Please do not provide any Personally Identifiable Information (PII)."
79 Product Improvement Both Provider and Non-provider
Please provide suggestions for new products to accompany and/or enhance your treatments/services. Free text If question is selected, please include the following text in the instrument instructions: "Please do not provide any Personally Identifiable Information (PII)."
80 Product Improvement Both Provider and Non-provider
What tools/technologies would help you/your patients that you don't have right now? Free text If question is selected, please include the following text in the instrument instructions: "Please do not provide any Personally Identifiable Information (PII)."
81 Product Improvement Both Provider and Non-provider
Do you have any suggestions regarding future products?
Free text If question is selected, please include the following text in the instrument instructions: "Please do not provide any Personally Identifiable Information (PII)."
82 Product Improvement Non-provider Rate how much you agree or disagree with the following product features: The product contains information that is useful. Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

83 Product Improvement Non-provider Rate how much you agree or disagree with the following product features: It is easy to access the product online.
Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

84 Product Improvement Non-provider Rate how much you agree or disagree with the following product features: It is easy to register to use the product.
Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

85 Product Improvement Provider Rate how much you agree or disagree with the following product features: Objectives of the <product/presentation/training> were clear to me.
Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

86 Product Improvement Provider Rate how much you agree or disagree with the following product features: It is easy to download the product.
Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

87 Product Improvement Provider Rate how much you agree or disagree with the following product features: It is easy to login to the product.
Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

88 Product Improvement Provider Rate how much you agree or disagree with the following product features: The product has a good mix of audio, video and text.
Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

89 Product Improvement Provider
What did you like least about this <product/website>? Free text If question is selected, please include the following text in the instrument instructions: "Please do not provide any Personally Identifiable Information (PII)."
90 Product Improvement Provider
Is there any information you would like to know about the subject that the <product/presentation/training> does not provide? Free text If question is selected, please include the following text in the instrument instructions: "Please do not provide any Personally Identifiable Information (PII)."
91 Product Improvement Provider
Please describe the aspects of the product you find least useful? Free text If question is selected, please include the following text in the instrument instructions: "Please do not provide any Personally Identifiable Information (PII)."
92 Product Referral Both Provider and Non-provider
If you would be comfortable recommending this product to others, please select all audiences that apply. A colleague
A supervisor
A patient
A friend
A family member
A fellow service member
A fellow veteran
Another service member in need
Other health care providers
I will not recommend this product
Other (Please specify) ____
If question is selected, please include the following text in the instrument instructions: "Please do not provide any Personally Identifiable Information (PII)."
93 Product Referral Both Provider and Non-provider Please rate how much you agree or disagree with the following: I recommend using telehealth services in the future Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

94 Product Referral Both Provider and Non-provider
How did you learn about this product? Select all that apply. Blog (Please specify) ____
Conference (Please specify) ____
Colleague
DCoE social media
DCoE website / listserv
Email from military community of interest
Family member / friend
Flier / marketing source
Internet search
Journal (Please specify) _____
Link from another website (Please specify) ____
Newsletter (Please specify) ____
Professional association
Provider
Someone in my chain of command
Training / webinar (Please specify) ____
DoD or Veteran Affairs website / listserv
Word of mouth
Yellow Ribbon Event (Please specify) ____
Other (Please specify) ____
If question is selected, please include the following text in the instrument instructions: "Please do not provide any Personally Identifiable Information (PII)."
95 Product Referral Both Provider and Non-provider
Where did you learn about the product? VA website
DCoE website
DCoE training
Journal
Social media
DoD website
DCoE webinar
Conference (please specify)
Colleague
Other (please specify)

96 Product Referral Provider
Why would you not recommend the product(s)? Free text If question is selected, please include the following text in the instrument instructions: "Please do not provide any Personally Identifiable Information (PII)."
97 Product Utilization Provider
Please rank the five topic areas that have the most clinical utility for your practice (Use "1" for your highest ranking and "5" for your lowest.) Alcohol and Drugs
Anger
Anxiety
Depression
Families and Friendships
Families with Kids
Health and Wellness
Life Stress
Mild Traumatic Brain Injury
Military Sexual Trauma
Physical Injury
Post-Traumatic Stress
Resilience
Spirituality
Stigma
Stress
Tobacco
Work Adjustment

98 Product Utilization Both Provider and Non-provider Rate how much you agree or disagree with the content of the <product/presentation/training>: The content is relevant to <me/my patients>.
Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

99 Product Utilization Both Provider and Non-provider Rate how much you agree or disagree with the content of the <product/presentation/training>: The content is applicable to my line of work.
Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

100 Product Utilization Both Provider and Non-provider
How often do you refer to the product? Daily
A few times a week
Weekly
Monthly
Annually
Every few years
Never

101 Product Utilization Both Provider and Non-provider
In your opinion, what factors prevent you from using the product?
Free text If question is selected, please include the following text in the instrument instructions: "Please do not provide any Personally Identifiable Information (PII)."
102 Product Utilization Both Provider and Non-provider
Which of the following products do you plan to integrate into your practice? Select all that apply. <insert product name>
<insert product name>
<insert product name>

103 Product Utilization Both Provider and Non-provider
What barriers are preventing you from using our products in your practice? Free text If question is selected, please include the following text in the instrument instructions: "Please do not provide any Personally Identifiable Information (PII)."
104 Product Utilization Both Provider and Non-provider
How will you integrate this product into your practice? Free text If question is selected, please include the following text in the instrument instructions: "Please do not provide any Personally Identifiable Information (PII)."
105 Product Utilization Both Provider and Non-provider
In what format would you prefer this product? Select all that apply. Hardcopy
Interactive online tool
Mobile application
Online video
Video/DVD
Website/Downloadable
Other (Please specify) ____

106 Product Utilization Both Provider and Non-provider
What would make you more likely to use <insert product name>? Free text If question is selected, please include the following text in the instrument instructions: "Please do not provide any Personally Identifiable Information (PII)."
107 Product Utilization Both Provider and Non-provider Please rate how much you agree or disagree with the following: Telehealth services are useful. Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

108 Product Utilization Both Provider and Non-provider
Who did you order this product for? Yourself
As an administrator for a clinic or military treatment facility
Provider

109 Product Utilization Non-provider Rate how much you agree or disagree about using this <product/presentation/training>: Using the product is preferable to working with a provider in person. Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

110 Product Utilization Provider
If you are a clinical provider, how would you use this product with patients? Free text If question is selected, please include the following text in the instrument instructions: "Please do not provide any Personally Identifiable Information (PII)."
111 Product Utilization Provider
What other kind of app or mobile technology might assist you and/or your patients? Free text If question is selected, please include the following text in the instrument instructions: "Please do not provide any Personally Identifiable Information (PII)."
112 Product Utilization Provider Rate how much you agree or disagree with the following product features: I had the necessary prerequisite knowledge <to use or understand the product/presentation/training>. Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree

113 Product Utilization Provider
What is the name of any similar product(s) you already use? Free text If question is selected, please include the following text in the instrument instructions: "Please do not provide any Personally Identifiable Information (PII)."
114 Product Utilization Provider
Please rate how likely you are to use the <product/website> again. Very Likely
Likely
Not Sure
Unlikely
Very Unlikely

115 Product Utilization Provider
What did you like most about this <product/website>? Free text If question is selected, please include the following text in the instrument instructions: "Please do not provide any Personally Identifiable Information (PII)."
116 Product Utilization Provider
What types of telehealth services have you provided?

(Telehealth is defined as the use of connecting technologies to provide services from a geographical distance, whether in real-time or otherwise.)
I have not had any experience providing telehealth services
Clinical video conferences
Interpretation of clinical images
Provider-to-provider consultations
Services involving telemedicine equipment
Support for telehealth sessions at the patient's end
Other forms of clinical care, supervision, education and monitoring, administration, or provider consultation and case management

117 Product Utilization Provider
When was the last time you used telehealth related methods? Less than 1 month
1 to 6 months
6 months to 1 year
1 to 2 years
2 or more years

118 Product Utilization Provider
How often do you refer to the product in your clinical practice? Very Frequently (more than once a week)
Frequently (weekly)
Sometimes (two or three times a month)
Rarely (once a month or less)
Never

119 Product Utilization Provider
Which Clinical Practice Guidelines (CPGs) do you refer to in your clinical practice? Select all that apply. <Insert product name>
<Insert product name>
<Insert product name>

120 Product Utilization Provider
How often do you use the product in your practice? Very Frequently (more than once a week)
Frequently (weekly)
Sometimes (two or three times a month)
Rarely (once a month or less)
Never

121 Product Utilization Provider
In what areas have clinical support tools impacted your practice? Select all that apply. Clinical decision-making
Screening
Assessment
Treatment
Provider collaboration
Patient education
No impact on my practice
Other (Please specify) ___
If question is selected, please include the following text in the instrument instructions: "Please do not provide any Personally Identifiable Information (PII)."
122 Product Utilization Provider
In your opinion, what factors prevent or impact you from using the product? Free text If question is selected, please include the following text in the instrument instructions: "Please do not provide any Personally Identifiable Information (PII)."
123 Product Utilization Provider
What would make you more likely to use the product? Free text If question is selected, please include the following text in the instrument instructions: "Please do not provide any Personally Identifiable Information (PII)."
124 Product Utilization Provider
Which product(s) did you order? Select all that apply. <Insert product name>
<Insert product name>
<Insert product name>

125 Product Utilization Provider
Please describe the aspects of the product you find most useful? Free text If question is selected, please include the following text in the instrument instructions: "Please do not provide any Personally Identifiable Information (PII)."
126 Product Utilization Provider
In what format would you prefer this product? Smart phone app
Paper copy
Digital copy
Video
Other (please specify) ______
If question is selected, please include the following text in the instrument instructions: "Please do not provide any Personally Identifiable Information (PII)."
127 Product Utilization Provider
Please provide additional comments that could improve awareness, usefulness, and implementation of the product in your clinical practice. Free text If question is selected, please include the following text in the instrument instructions: "Please do not provide any Personally Identifiable Information (PII)."
128 Product Utilization Provider
How would you rate your knowledge of the topic before using this product? Well above average
Above average
Average
Below average
Well below average
To ask about knowledge after use of the product, use question 40.

Sheet 3: Data Dictionary

Question Focus The question is intened to:
Contact Preference Provides guidance regarding preferance, frequency and mode for follow-up
Demographic Provide a picture of the respondent audience
Product Efficiency Provide insight into whether the product increases knowledge and/or productivity
Product Improvement Provides insight into product requirements (i.e., features, function, content)
Product Impact Provide insight into whether the product results in a change in behavior or practice
Product Effectiveness Provide insight into the results a product provides
Product Referral Provide insight into who and/or how often products are recommended to others
Product Utilization Provide insight into the adoption / level of use for a product
Target Audience The respondent role may include:
Non-Provider Service members, veterans, their families and caregivers; collaborative partners
Provider Health care providers (i.e., doctor, nurse, dentist, social worker, etc.)
File Typeapplication/vnd.openxmlformats-officedocument.spreadsheetml.sheet
File Modified0000-00-00
File Created0000-00-00

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