Attachment K: Online Surveys_Summary Product

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Survey for Site Visitors Downloading Products (initial survey)

Please help us improve the materials that we design for you by answering the two questions below.

We are very appreciative of your assistance.

1. Are you accessing this information for yourself or someone else?

_____ For myself

_____ For a relative

_____ For a friend or someone else

_____ For a patient of mine

2. How do you expect to use the information in this health topic summary? [select ALL that apply]

_____ I will use this information to help me make a health care decision

_____ I will give this information to someone else to help them make a health care decision

_____ I want to learn more about this topic

_____ Other reason, please describe: ____________________________________________

If you would be willing to answer a follow-up 2-minute survey in two weeks, please provide your email below.

[You will receive one email from us. You will not be sent advertisements, solicitations, or any other email messages. Nor will your email address be shared with any other person or organization.]

Email address: ________________________________________________________________

Public reporting burden for this collection of information is estimated to average 5 minutes per response, the estimated time required to complete the survey. 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: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

Your responses will be kept confidential to the extent permitted by law, including AHRQ’s confidentiality statute, 42 USC 299c-3(c).

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Survey for Site Visitors Downloading Products (follow up)

Two weeks ago you accessed or downloaded one or more health topic summaries from the AHRQ Effective Health Care web site. Please take a moment to answer the brief follow-up questions below.

Thank you very much for your time.

1. How did you use the information in the health topic summary that you downloaded?

[select ALL that apply]

_____ I already used the information to help me make a health care decision

_____ I am using the information to help me with a health care decision that I am in the process of making

_____ I shared the information with someone else who is making a health care decision related to this topic

_____ I used the information to learn more this topic [program to SKIP to item #3]

_____ I have not yet read the information, but still plan to. [program to SKIP to end of survey]

_____ I did not find the information useful. [program to SKIP to item #4]

_____ Other reason, please describe: ____________________________________________

_____ I do not recall [program to SKIP to end of survey]

2. Did the information help you or someone you know make a more informed decision?

[select ALL that apply]

_____ Yes

_____ I am not sure / don’t know

_____ No

3. What did you like or find useful about the health topic summary?

[open text box]

4. Please describe any ways in which the health topic summary could be improved or any barriers that you faced in using this information:

[open text box]

Public reporting burden for this collection of information is estimated to average 5 minutes per response, the estimated time required to complete the survey. 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: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

Your responses will be kept confidential to the extent permitted by law, including AHRQ’s confidentiality statute, 42 USC 299c-3(c).