CDC-INFO Email Survey

Form Approved

OMB No. 0920-1050

Expires 06/30/2019

CDC-INFO Email Survey

These set of questions will help CDC-INFO learn more about your experience with our service.

1. How satisfied are you with your experience with CDC-INFO?

• Very satisfied

• Satisfied

• Neutral

• Dissatisfied

• Very Dissatisfied

2. Did you receive the health information you were looking for?

• Yes

• No (if selected, goes to 2a)

1. What information did you hope to find but did not receive? [Open Ended]

3. Based on the information you received from CDC-INFO today, how likely are you to make changes regarding your or your family’s behavior?

• Not Applicable

• Very Likely (if selected, goes to 3a)

• Likely (if selected, goes to 3a)

• Not Likely (if selected, goes to 3b)

• Not Likely at all (if selected, goes to 3b)

1. You mentioned you are likely to make changes regarding your or your family’s behavior based on the information you received. What kind of changes do you intend to make? Please describe below. [Open Ended]

2. You mentioned you are unlikely to make changes regarding your or your family’s behavior based on the information you received. What is the main reason you are unlikely to do so? Select all that apply.

• I am uncertain about what to do with the information received.

• I do not think the information received was helpful.

• I do not have enough resources or information to do the recommended behavior at this time.

• I prefer not to answer.

• Other (please specify):_____________

These set of questions will help CDC-INFO learn more about the people we’re reaching with our email service.

4. Are you male or female?

• Male

• Female

5. How old are you?

• Age 19 or under

• 20-34 years old

• 35-49 years old

• 50-64 years old

• Age 65 or older

6. What ethnicity do you identify with?

• Hispanic or Latino

• Not Hispanic or Latino

7. Which one or more of the following would you say is your race? Select all that apply.

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or Other Pacific Islander

• White

8. What other forms of communication you would like CDC-INFO to offer? Select all that apply.

• Mobile-friendly website

• Facebook

• Twitter

• Live chat

• Other (Please specify)

Public reporting burden of this collection of information is estimated to average 6 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 CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74,  Atlanta, Georgia 30333; ATTN:  PRA (0920-1050).