Sample Survey

U.S. Department of Health and Human Services (HHS)                        OMB Control # 0920-0932

Centers for Disease Control and Prevention (CDC)                               Expiration Date XX/XX/XXXX

1

Healthcare Provider Questions

Q1. How much do you like the message <insert main tagline here> for your patients?

0=Do not like it at all, 10=Like it extremely well

Q2. Overall, how well do the following phrases describe the ad above?

0=Does not describe at all, 10=Describes perfectly

• Easy for patients to understand

• Provides appropriate advice to patients

• Is relevant to my patients

Q3. For each of the following statements below, how effective do you think the ad shown above

is in…

0=Not effective at all, 10=Extremely effective

• Motivating your patients not to travel when they have the flu

• Making your patients take the issue of traveling with the flu more seriously

• Making your patients think differently than they have in the past about traveling when
  they have the flu

Q4. Based on this ad, how likely do you think your patients would be to look for more information about these messages?

0=Definitely would NOT look for more information, 10=Definitely would look for more information

Also add: “I don’t know”

Q5. Thinking about the ad shown above, please indicate how much you agree or disagree with each of the following statements.

Across top: Disagree Disagree Neither Agree Agree Agree

Completely Somewhat Nor Disagree Somewhat Completely

1 2 3 4 5

This ad…

• Will get my -patients’ attention

• Tells my patients how to prevent the flu during travel

• Motivates my patients to travel only when they are feeling well

• Shows patients that CDC is concerned about preventing flu during travel

Q6. Based on the message “<insert tagline>,” how willing would you be to disburse these materials directly to your patients?

0=Not at all willing, 10=Very willing

<if respondent chooses 0-5 for willingness, then ask Q6 below>

Q7. What format of materials would be helpful to use with your patients? (Rank by preference)

• Postcard

• Brochure

• Flyer

• Poster

• Video

• E-mail template

• Materials to post on website

• Other: __________________

• I would not use these materials.

Q8. Which of the following channels do you feel is the best for disbursing travel health information to patients?

• Primary care physician

• Other health-care provider

• Travel medicine clinic

• Family and friends

• Travel agents or tour operators

• Health-related websites such as WebMD

• CDC website

• Other websites (please specify) _____________________

• Books

• Other (please specify) __________________________

Q9. How helpful do you feel this type of public information campaign from the CDC is to the
traveling public?

0=Not at helpful, 10=Very helpful

<Display all concepts together on one page with “mouse-over” magnification for Q9-10>

Q10. Which of the ads displayed below do you think would be best at catching your patients’ attention? (Select one)

Q11. Which of the ads displayed below is most appropriate for delivering this important information to patients and potential patients? (Select one)

Q12. How willing would you be to distribute these materials to your patients?

0=Not at all willing, 10=Very willing

Q13. In the previous question you indicated some reluctance to disburse the campaign material shown above. Please tell us both:

• Why would you be reluctant to share the material? (open ended) ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

• How can we improve it? (open ended)

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Public reporting burden of this collection of information is estimated to average 45 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor a project, 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 Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-0932.