0920-1154 Pop-Up Invitation to Survey - Website User

Attachment 6 - Information Collection Instrument- Survey of Website Users

Form Approved

OMB No. 0920-1154

Exp. Date : xx/xx/2021

xx/xx/20xx

Pop-Up Survey Invitation and Survey

Thank you for visiting our website. You have been selected to participate in a brief satisfaction survey to let us know how we can improve your experience. This will take one minute of your time. If you would like to provide feedback on your experience at this time, please choose ‘Start Survey’. Otherwise, please choose ‘Not at this Time’.

Not at this Time

Start Survey

By clicking Start Survey, you are leaving the Zika Care Connect website. Thank you again for visiting.

Note to reviewer: This will be an online survey.

Thank you for visiting Zika Care Connect. You have been selected to participate in a brief survey to let us know what we are doing well and where we can improve. Your survey results are completely confidential.

Please take a few minutes to share your opinions, which are essential in helping us provide the best experience possible. You can skip any question that you do not wish to answer.

1. How old are you?

   1. Under 18 (Exclude Message to be Displayed: Thank you for your participation. You may click here (insert link to ZCC) to be directed back to the ZCC website. If you have additional thoughts or feedback please contact us at the ZCC HelpLine, 1-844-677-0447 or [email protected].)

   2. 18-25

   3. 26-35

   4. 36-45

   5. 46-55

   6. 56-65

   7. 66-75

   8. 76-85

   9. Older than 85

2. In what state do you live? (Drop-down menu to include US territories, International, and Other)

3. Are you a healthcare professional? (If no: Skip to Q5)

4. If yes to Question 3: What is your healthcare specialty?

5. What was the reason for your visit to www.zikacareconnect.com today? Please check all that apply.

   1. To find a healthcare professional

   2. To learn about Zika virus (Zika)

   3. To find Zika resources

   4. To enroll as a healthcare professional in Zika Care Connect

   5. Other (free text)

6. On a scale from 1-5 (Note to reviewer: scale will be included on survey instrument, 1: Not at all Resolved, 5: Completely Resolved), was your reason for visiting resolved?

7. On a scale from 1-5 (Note to reviewer: scale will be included on survey instrument, 1: Not at all Satisfied, 5: Completely Satisfied), how satisfied are you with your experience today?

8. Please explain your satisfaction rating. (Free text response)

9. If Q5 was A (all others skip to Q14): After visiting the website today, are you now able to identify a specialty care healthcare professional?

   1. Yes

   2. No

   3. Not sure

10. Did you schedule an appointment with a healthcare professional you found on the ZCC website?

    1. Yes

    2. No, but I intend to

    3. No, and I do not intend to

    4. Not sure

11. Which of the following information provided about the healthcare professionals did you review on the Zika Care Connect website? Select all that apply.

    1. Healthcare Professional Name

    2. Practice Name

    3. Address

    4. Phone Number

    5. Website

    6. Hospital System

    7. Office Hours

    8. Insurance Accepted

    9. Directions to the office

    10. Availability of coordinated care

    11. Board certification of healthcare professional

    12. Other office locations available

    13. Other specialists from this system enrolled in ZCC

    14. Services offered by the healthcare professional

    15. Other notes

    16. None of these

12. Please select the top three most helpful pieces of information about the healthcare professional that was presented.

(Note: Use same list from Q11)

13. What, if any, additional information would you like to have provided about the healthcare professionals enrolled in the ZCC Network? (Open Ended)

If Q3 was no (patient) answer Q14, If Q3 was Yes (provider) skip to Q22.

14. To your knowledge, what care may be needed for an infant with congenital Zika syndrome? Please select all that apply.

    1. Eye exam

    2. Head MRI/CT

    3. Hearing screening

    4. Head Ultrasound

    5. Neurological exam

    6. Thyroid screening

    7. Well-baby visit

    8. None of these

    9. Not sure

15. To your knowledge, what types of healthcare professional specialists are recommended to care for a pregnant woman or infant with Zika virus? Please select all that apply.

    1. Audiologist

    2. Care Coordinator

    3. Developmental Pediatrician

    4. Endocrinologist

    5. Infectious Disease

    6. Maternal Fetal Medicine

    7. Mental Health Clinician

    8. Neurologist

    9. Ophthalmologist

    10. Radiologist

    11. Other: ________

    12. None of these

    13. Not sure

16. Did you read about care coordination on the ZCC website today?

    1. Yes

    2. No

    3. Not Sure

17. How important is care coordination for the management of Zika virus?

    1. Not at all important

    2. Slightly important

    3. Somewhat important

    4. Moderately important

    5. Extremely important

    6. Not Sure

18. True or False: Coordinated care is the process of ensuring all the different healthcare providers and healthcare facilities communicate about medical care.

    1. True

    2. False

    3. Not Sure

19. Please rate how helpful ZCC was in informing you of recommended services for the management of Zika virus symptoms.

    1. Not at all helpful

    2. Slightly helpful

    3. Somewhat helpful

    4. Moderately helpful

    5. Extremely helpful

    6. That was not the reason for my visit today

    7. Not Sure

20. Please rate how helpful ZCC was in identifying providers for the management of Zika virus symptoms.

    1. Not at all helpful

    2. Slightly helpful

    3. Somewhat helpful

    4. Moderately helpful

    5. Extremely helpful

    6. That was not the reason for my visit today

    7. Not Sure

21. Please rate how helpful ZCC was in describing coordinated care.

    1. Not at all helpful

    2. Slightly helpful

    3. Somewhat helpful

    4. Moderately helpful

    5. Extremely helpful

    6. That was not the reason for my visit today

    7. Not sure

22. How did you hear about Zika Care Connect?

    1. Healthcare Professional

    2. Friend

    3. Website Search

    4. Social Media (e.g. Twitter, Facebook)

    5. News Article

    6. CDC Website

    7. March of Dimes Website

    8. Other Website

    9. Professional Organization

    10. Health Department

    11. Other (please specify)

    12. Not Sure

23. Do you plan to visit the Zika Care Connect website again in the future?

    1. Yes

    2. No (Skip to Q25)

    3. Not sure (Skip to Q26)

24. Please explain your reasons for planning to visit the Zika Care Connect website in the future. (Skip to Q26)

25. Please explain your reasons for not planning to visit the Zika Care Connect website in the future.

26. What, if any, additional information or resources would you like to see on the Zika Care Connect website?

Survey Close: Thank you for providing feedback on your experience with Zika Care Connect. You may click here (insert link to ZCC) to be directed back to the ZCC website. If you have additional thoughts or feedback please contact us at the ZCC HelpLine, 1-844-677-0447 or [email protected].

Public reporting burden of this collection of information is estimated to average 5 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 (0920-1154).