| 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. |
| 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. |
| 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 Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |