Form 020 2020 021 Foresee_Q_SAMHSAStore_Web_Browse updated April

E-Government Website Customer Satisfaction Surveys

2020 021 Foresee_Q_SAMHSAStore_Web_Browse updated April 8 2020.xlsx

2020 021 Foresee_Q_SAMHSAStore_Web_Browse updated April 8 2020

OMB: 1090-0008

Document [xlsx]
Download: xlsx | pdf

Overview

Model Qsts
Current CQs
CQs (04-14-2020)
CQs 4-8-20
CQs (6-8-16)
CQs (12-17-15)
CQs 7-11-2013


Sheet 1: Model Qsts

Model Instance Name:



red & strike-through: DELETE


SAMHSA Store V2



underlined & italicized: RE-ORDER


MID: AlJRpZ1w1xJYE9MMtg8JdA==



pink: ADDITION


Date:
7/16/2013
blue + -->: REWORDING


SAMHSA Store V2
Model questions utilize the ACSI methodology to determine scores and impacts


ELEMENTS (drivers of satisfaction)

CUSTOMER SATISFACTION

FUTURE BEHAVIORS


Navigation (1=Poor, 10=Excellent, Don't Know)

Satisfaction

Return (1=Very Unlikely, 10=Very Likely)
1 Navigation - Organized Please rate how well the site is organized. 16 Satisfaction - Overall What is your overall satisfaction with this site?
(1=Very Dissatisfied, 10=Very Satisfied)
19 Return How likely are you to return to this site?
2 Navigation - Options Please rate the options available for navigating this site. 17 Satisfaction - Expectations How well does this site meet your expectations?
(1=Falls Short, 10=Exceeds)


Recommend (1=Very Unlikely, 10=Very Likely)
3 Navigation - Layout Please rate how well the site layout helps you find what you are looking for. 18 Satisfaction - Ideal How does this site compare to your idea of an ideal website? (1=Not Very Close, 10=Very Close) 20 Recommend How likely are you to recommend this site to someone else?


Site Performance (1=Poor, 10=Excellent, Don't Know)




Primary Resource (1=Very Unlikely, 10=Very Likely)
4 Site Performance - Loading Please rate how quickly pages load on this site.


21 Primary Resource How likely are you to use this site as your primary resource for obtaining information and ordering publications from this agency?
5 Site Performance - Consistency Please rate the consistency of speed from page to page on this site.





6 Site Performance - Errors Please rate the ability to load pages without getting error messages on this site.







Site Information (1=Poor, 10=Excellent, Don't Know)


7 Site Information - Thoroughness Please rate the thoroughness of information provided on this site.
8 Site Information - Understandable Please rate how understandable this site’s information is.
9 Site Information - Answers Please rate how well the site’s information provides answers to your questions.


Look and Feel (1=Poor, 10=Excellent, Don't Know)





10 Look and Feel - Appeal Please rate the visual appeal of this site.





11 Look and Feel - Balance Please rate the balance of graphics and text on this site.





12 Look and Feel - Readability Please rate the readability of the pages on this site.







Information Browsing (1=Poor, 10=Excellent, Don't Know)





13 Product Browsing - Sort Please rate the ability to sort information by criteria that are important to you on this site.





14 Product Browsing - Narrow Please rate the ability to narrow choices to find the information you are looking for on this site.





15 Product Browsing - Features Please rate how well the features on the site help you find the information you are looking for.






Sheet 2: Current CQs

Model Instance Name:
red & strike-through: DELETE





SAMHSA Store V2
underlined & italicized: RE-ORDER





MID: YItkJ4B5FR1E0Q5tk49Zow4C

pink: ADDITION





Date: 5/18/16
blue + -->: REWORDING














SAMHSA Store V2 CUSTOM QUESTION LIST

QID
(Group ID)
Skip Logic Label Question Text Answer IDs (DOT ONLY) Answer Choices
(limited to 50 characters)
Skip to Type (select from list) Single or Multi Required
Y/N
Special Instructions CQ Label
MAC1878
How frequently do you visit the SAMHSA Store? MAC1878A01 First time
Drop down, select one S Y
Frequency of visits


MAC1878A02 Daily






MAC1878A03 Weekly






MAC1878A04 Monthly






MAC1878A05 Every few months or less often




MAC1879
What is your primary interest in substance abuse and mental health topics? MAC1879A01 Personal A1-A3 Drop down, select one S Y Skip Logic Group Primary interest


MAC1879A02 Professional B1-B4




MAC1880 A1 For whom are you looking up information and resources? MAC1880A01 Yourself
Radio button, one-up vertical S Y Skip Logic Group Personal info for


MAC1880A02 Family member







MAC1880A03 Friend





MAC1881 A2 What is the age of the person for whom you are seeking resources? MAC1881A01 12 and under
Radio button, one-up vertical S Y Skip Logic Group Personal age


MAC1881A02 13 to 17







MAC1881A03 18 to 24







MAC1881A04 25 to 34







MAC1881A05 35 to 44







MAC1881A06 45 to 54







MAC1881A07 55 to 64







MAC1881A08 65 and older





MAC1882 A3 Are you primarily looking for information on any of the following topics? MAC1882A01 Treatment and recovery A4 Radio button, one-up vertical S Y Skip Logic Group Personal info topic


MAC1882A02 Preventing substance abuse problems A5






MAC1882A03 Preventing mental illness/promoting mental wellness A6






MAC1882A04 Helping someone cope with and recover from a traumatic event A7






MAC1882A05 Other, please specify A8




MAC1883 A4 Please specify the topic of interest for treatment and recovery. (Check all that apply) MAC1883A02 Understanding different types of treatment
Checkbox, one-up vertical M Y Skip Logic Group Personal treatment


MAC1883A05 Information about specific substances of abuse







MAC1883A06 Information about specific mental illnesses





MAC1884 A5 Please specify the topic of interest for substance abuse prevention. (Check all that apply) MAC1884A01 Alcohol
Checkbox, one-up vertical M Y Skip Logic Group Personal SA prevention



Marijuana







MAC1884A03 Prescription drugs







MAC1884A04 Tobacco







MAC1884A02 Other substances (e.g., cocaine, heroin)





MAC1885 A6 Please specify the topic of interest for preventing mental illness and promoting mental wellness. (Check all that apply) MAC1885A01 Anger management
Checkbox, one-up vertical M Y Skip Logic Group Personal MH illness


MAC1885A02 Anxiety or depression







MAC1885A03 Bullying prevention







MAC1885A04 Eating disorders







MAC1885A05 PTSD







MAC1885A06 Schizophrenia







MAC1885A07 Stress management







MAC1885A08 Suicide prevention





MAC1886 A7 Please specify the topic of interest for trauma recovery. (Check all that apply) MAC1886A01 Death of a loved one
Checkbox, one-up vertical M Y Skip Logic Group Personal trauma


MAC1886A02 Physical or sexual abuse







MAC1886A03 Natural disaster







MAC1886A04 Mass violence







MAC1886A05 Post-military deployment





MAC1887 A8 Please specify other information looking for.


Text area, no char limit
N Skip Logic Group Personal other info
MAC1888 B1 What best describes your organization type? MAC1888A01 Behavioral health treatment facility
Radio button, one-up vertical S Y Skip Logic Group Organization type



Criminal justice/courts







Health insurer







Human resources/employee assistance program







Individual or group private practice







Managed care/insurance company office







Military/veterans group







Nonprofit/community-based organization/coalition






MAC1888A02 Non-residential/out-patient facility






MAC1888A05 Public place/Interacting in community






MAC1888A06 Residential/in-patient facility






MAC1888A08 School/university






MAC1888A10 Other A



NEL0120898 A Please specify your organization.

Text area, no char limit
N Skip Logic Group Organization type Other
MAC1889 B2 For whom are you primarily looking for information and resources? MAC1889A01 Professional education for self/colleagues
Radio button, one-up vertical S Y Skip Logic Group Professional info for


MAC1889A02 Use with patients/clients







MAC1889A03 Use within classroom/youth setting







MAC1889A04 Public awareness campaign/event







MAC1889A05 Other





MAC1890 B3 Which of the following best describes the age of your patients, clients, or students? MAC1890A01 12 and under
Radio button, one-up vertical S Y Skip Logic Group Professional age


MAC1890A02 13 to 17







MAC1890A03 18 to 24







MAC1890A04 25 to 34







MAC1890A05 35 to 44







MAC1890A06 45 to 54







MAC1890A07 55 to 64







MAC1890A08 65 and older





MAC1891 B4 Were you primarily looking for information on any of the following topics? MAC1891A02 Treatment and recovery B6 Radio button, one-up vertical S Y Skip Logic Group Professional info topic


MAC1891A03 Substance abuse prevention B7






MAC1891A04 Preventing mental illness/promoting mental wellness B8






MAC1891A05 Trauma B9






MAC1891A06 Other, please specify B10




MAC1893 B6 Please specify the topic of interest for treatment and recovery. (Check all that apply) MAC1893A01 Patient/client educational materials
Checkbox, one-up vertical M Y Skip Logic Group Professional treatment


MAC1893A02 Evidence based practices







MAC1893A03 Information for working with specific populations







MAC1893A04 Information about specific substances of abuse







MAC1893A05 Information about specific mental illnesses





MAC1894 B7 Please specify the topic of interest for substance abuse prevention. (Check all that apply) MAC1894A01 Alcohol
Checkbox, one-up vertical M Y Skip Logic Group Professional SA prevention



Marijuana







MAC1894A03 Prescription drugs







MAC1894A04 Tobacco







MAC1894A02 Other substances (e.g., cocaine, heroin)







MAC1894A05 Parenting/family resources





MAC1895 B8 Please specify the topic of interest for preventing mental illness and promoting mental wellness. (Check all that apply) MAC1895A01 Anger management
Checkbox, one-up vertical M Y Skip Logic Group Professional MH illness


MAC1895A02 Bullying prevention







MAC1895A03 Eating disorders







MAC1895A04 Mood disorders







MAC1895A05 PTSD







MAC1895A06 Schizophrenia







MAC1895A07 Stress management







MAC1895A08 Suicide prevention







MAC1895A09 Parenting/family resources





MAC1896 B9 Please specify the topic of interest for trauma. (Check all that apply) MAC1896A01 Grief
Checkbox, one-up vertical M Y Skip Logic Group Professional trauma


MAC1896A02 Physical or sexual abuse







MAC1896A03 Natural disaster







MAC1896A04 Mass violence







MAC1896A05 Post-military deployment





MAC1897 B10 Please specify other information looking for.


Text area, no char limit
N Skip Logic Group Professional other info
MAC1898
Did you find what you were looking for? MAC1898A01 Yes
Drop down, select one S Y
Find info


MAC1898A02 No






MAC1898A03 Partially






MAC1898A04 Still looking




MAC1899
How satisfied were you with the content available? MAC1899A01 Very satisfied
Drop down, select one S Y Skip Logic Group Content satisfaction



MAC1899A02 Somewhat satisfied








MAC1899A03 No opinion








MAC1899A04 Somewhat dissatisfied A







MAC1899A05 Very dissatisfied A




MAC1900 A Please tell us how our products and resources could be improved.


Text area, no char limit
N Skip Logic Group Improve products
MAC1901
What services could this agency provide to better serve you?


Text area, no char limit
N
Other services wanted
MAC1902
Please specify the types of electronic devices you use. (Check all that apply) MAC1902A01 Desktop or laptop computer
Checkbox, one-up vertical M Y
Device type


MAC1902A02 Tablet or e-reader (e.g., iPad, Kindle, Nook)







MAC1902A03 Smartphone (e.g., iPhone or similar devices with web access)







MAC1902A04 Cell phone





The following demographics questions are entirely optional and will be used for statistical purposes only.
MAC1903
What is your gender? MAC1903A01 Female
Drop down, select one S N
Gender


MAC1903A02 Male






MAC1903A03 Prefer not to respond




MAC1904
Please select the category that includes your age. MAC1904A01 17 and under
Drop down, select one S N
Age


MAC1904A02 18 - 24






MAC1904A03 25 - 34






MAC1904A04 35 - 44






MAC1904A05 45 - 54






MAC1904A06 55 - 64






MAC1904A07 65 and over






MAC1904A08 Prefer not to respond




MAC1905
Which of the following best describes the highest level of education you have completed? MAC1905A01 Current middle or high school student
Drop down, select one S N
Education


MAC1905A02 Did not complete high school






MAC1905A03 High school graduate






MAC1905A04 Some college/vocational school






MAC1905A05 College graduate






MAC1905A06 Some postgraduate school






MAC1905A07 Graduate/professional degree






MAC1905A08 MD/PhD






MAC1905A09 Prefer not to respond




CUE0405850
Where do you live? CUE0405850A001 United States A Drop down, select one S N Skip Logic Group Location



CUE0405850A002 U.S. Territories or Possessions B







CUE0405850A003 International (please specify) C




MAC1906 A Please select your state. MAC1906A01 Alabama
Drop down, select one S N
State


MAC1906A02 Alaska



Skip Logic Group


MAC1906A03 Arizona






MAC1906A04 Arkansas






MAC1906A05 California






MAC1906A06 Colorado






MAC1906A07 Connecticut






MAC1906A08 Delaware






MAC1906A09 Florida






MAC1906A10 Georgia






MAC1906A11 Hawaii






MAC1906A12 Idaho






MAC1906A13 Illinois






MAC1906A14 Indiana






MAC1906A15 Iowa






MAC1906A16 Kansas






MAC1906A17 Kentucky






MAC1906A18 Louisiana






MAC1906A19 Maine






MAC1906A20 Maryland






MAC1906A21 Massachusetts






MAC1906A22 Michigan






MAC1906A23 Minnesota






MAC1906A24 Mississippi






MAC1906A25 Missouri






MAC1906A26 Montana






MAC1906A27 Nebraska






MAC1906A28 Nevada






MAC1906A29 New Hampshire






MAC1906A30 New Jersey






MAC1906A31 New Mexico






MAC1906A32 New York






MAC1906A33 North Carolina






MAC1906A34 North Dakota






MAC1906A35 Ohio






MAC1906A36 Oklahoma






MAC1906A37 Oregon






MAC1906A38 Pennsylvania






MAC1906A39 Rhode Island






MAC1906A40 South Carolina






MAC1906A41 South Dakota






MAC1906A42 Tennessee






MAC1906A43 Texas






MAC1906A44 Utah






MAC1906A45 Vermont






MAC1906A46 Virginia






MAC1906A47 Washington






MAC1906A48 Washington D.C.






MAC1906A49 West Virginia






MAC1906A50 Wisconsin






MAC1906A51 Wyoming






MAC1906A52 Prefer not to respond




CUE0405851 B Please select your place of residence. CUE0405851A001 American Samoa
Drop down, select one S N Skip Logic Group Territory



CUE0405851A002 Guam








CUE0405851A003 Northern Mariana Islands








CUE0405851A004 Puerto Rico








CUE0405851A005 U.S. Virgin Islands





CUE0405852 C Please specify your country. new

Text area, 100 character limit
N Skip Logic Group OE_International
MAC1907
Are you living in a: MAC1907A01 Urban area
Drop down, select one S N
Living area


MAC1907A02 Rural area






MAC1907A03 Don't know




MAC1908
How do you describe your ethnicity? MAC1908A01 Hispanic
Drop down, select one S N
Ethnicity


MAC1908A02 Non-Hispanic






MAC1908A03 Prefer not to respond




MAC1909
How do you describe your race? MAC1909A01 American Indian or Alaska Native
Drop down, select one S N
Race


MAC1909A02 Asian or Pacific Islander






MAC1909A03 African American or Black






MAC1909A04 White






MAC1909A05 Other






MAC1909A06 Prefer not to respond





Sheet 3: CQs (04-14-2020)

Model Instance Name:
red & strike-through: DELETE





SAMHSA Store V2
underlined & italicized: RE-ORDER





MID: YItkJ4B5FR1E0Q5tk49Zow4C

pink: ADDITION





Date: 5/18/16
blue + -->: REWORDING














SAMHSA Store V2 CUSTOM QUESTION LIST

QID
(Group ID)
Skip Logic Label Question Text Answer IDs (DOT ONLY) Answer Choices
(limited to 50 characters)
Skip to Type (select from list) Single or Multi Required
Y/N
Special Instructions CQ Label
MAC1878
How frequently do you visit the SAMHSA Store? MAC1878A01 First time
Drop down, select one S Y
Frequency of visits


MAC1878A02 Daily






MAC1878A03 Weekly






MAC1878A04 Monthly






MAC1878A05 Every few months or less often




MAC1879
What is your primary interest in substance abuse and mental health topics? MAC1879A01 Personal A1-A3 Drop down, select one S Y Skip Logic Group Primary interest


MAC1879A02 Professional B1-B4




MAC1880 A1 For whom are you looking up information and resources? MAC1880A01 Yourself
Radio button, one-up vertical S Y Skip Logic Group Personal info for


MAC1880A02 Family member







MAC1880A03 Friend





MAC1881 A2 What is the age of the person for whom you are seeking resources? MAC1881A01 12 and under
Radio button, one-up vertical S Y Skip Logic Group Personal age


MAC1881A02 13 to 17







MAC1881A03 18 to 24







MAC1881A04 25 to 34







MAC1881A05 35 to 44







MAC1881A06 45 to 54







MAC1881A07 55 to 64







MAC1881A08 65 and older





MAC1882 A3 Are you primarily looking for information on any of the following topics? MAC1882A01 Treatment and recovery A4 Radio button, one-up vertical S Y Skip Logic Group Personal info topic


MAC1882A02 Preventing substance abuse problems A5






MAC1882A03 Preventing mental illness/promoting mental wellness A6






MAC1882A04 Helping someone cope with and recover from a traumatic event A7






MAC1882A05 Other, please specify A8




MAC1883 A4 Please specify the topic of interest for treatment and recovery. (Check all that apply) MAC1883A01 Options for paying for treatment
Checkbox, one-up vertical M Y Skip Logic Group Personal treatment


MAC1883A02 Understanding different types of treatment







MAC1883A03 Identifying a treatment professional or facility







MAC1883A04 Recovery support services (e.g., support groups)







MAC1883A05 Information about specific substances of abuse







MAC1883A06 Information about specific mental illnesses





MAC1884 A5 Please specify the topic of interest for substance abuse prevention. (Check all that apply) MAC1884A01 Alcohol
Checkbox, one-up vertical M Y Skip Logic Group Personal SA prevention



Marijuana







MAC1884A03 Prescription drugs







MAC1884A04 Tobacco







MAC1884A02 Other substances (e.g., cocaine, heroin)





MAC1885 A6 Please specify the topic of interest for preventing mental illness and promoting mental wellness. (Check all that apply) MAC1885A01 Anger management
Checkbox, one-up vertical M Y Skip Logic Group Personal MH illness


MAC1885A02 Anxiety or depression







MAC1885A03 Bullying prevention







MAC1885A04 Eating disorders







MAC1885A05 PTSD







MAC1885A06 Schizophrenia







MAC1885A07 Stress management







MAC1885A08 Suicide prevention





MAC1886 A7 Please specify the topic of interest for trauma recovery. (Check all that apply) MAC1886A01 Death of a loved one
Checkbox, one-up vertical M Y Skip Logic Group Personal trauma


MAC1886A02 Physical or sexual abuse







MAC1886A03 Natural disaster







MAC1886A04 Mass violence







MAC1886A05 Post-military deployment





MAC1887 A8 Please specify other information looking for.


Text area, no char limit
N Skip Logic Group Personal other info
MAC1888 B1 What best describes your organization type? MAC1888A01 Behavioral health treatment facility
Radio button, one-up vertical S Y Skip Logic Group Organization type



Criminal justice/courts







Health insurer







Human resources/employee assistance program







Individual or group private practice







Managed care/insurance company office







Military/veterans group







Nonprofit/community-based organization/coalition






MAC1888A02 Non-residential/out-patient facility






MAC1888A05 Public place/Interacting in community






MAC1888A06 Residential/in-patient facility






MAC1888A08 School/university






MAC1888A10 Other A



NEL0120898 A Please specify your organization.

Text area, no char limit
N Skip Logic Group Organization type Other
MAC1889 B2 For whom are you primarily looking for information and resources? MAC1889A01 Professional education for self/colleagues
Radio button, one-up vertical S Y Skip Logic Group Professional info for


MAC1889A02 Use with patients/clients







MAC1889A03 Use within classroom/youth setting







MAC1889A04 Public awareness campaign/event







MAC1889A05 Other





MAC1890 B3 Which of the following best describes the age of your patients, clients, or students? MAC1890A01 12 and under
Radio button, one-up vertical S Y Skip Logic Group Professional age


MAC1890A02 13 to 17







MAC1890A03 18 to 24







MAC1890A04 25 to 34







MAC1890A05 35 to 44







MAC1890A06 45 to 54







MAC1890A07 55 to 64







MAC1890A08 65 and older





MAC1891 B4 Were you primarily looking for information on any of the following topics? MAC1891A01 Affordable Care Act (e.g., health reform, parity) B5 Radio button, one-up vertical S Y Skip Logic Group Professional info topic


MAC1891A02 Treatment and recovery B6






MAC1891A03 Substance abuse prevention B7






MAC1891A04 Preventing mental illness/promoting mental wellness B8






MAC1891A05 Trauma B9






MAC1891A06 Other, please specify B10




MAC1892 B5 Please specify the topic of interest for Affordable Care Act. (Check all that apply) MAC1892A01 Reimbursement for behavioral health services
Checkbox, one-up vertical M Y Skip Logic Group Professional ACA


MAC1892A02 Enrolling patients/clients in health insurance exchanges or Medicaid/Medicare







MAC1892A03 Other





MAC1893 B6 Please specify the topic of interest for treatment and recovery. (Check all that apply) MAC1893A01 Patient/client educational materials
Checkbox, one-up vertical M Y Skip Logic Group Professional treatment


MAC1893A02 Evidence based practices







MAC1893A03 Information for working with specific populations







MAC1893A04 Information about specific substances of abuse







MAC1893A05 Information about specific mental illnesses





MAC1894 B7 Please specify the topic of interest for substance abuse prevention. (Check all that apply) MAC1894A01 Alcohol
Checkbox, one-up vertical M Y Skip Logic Group Professional SA prevention



Marijuana







MAC1894A03 Prescription drugs







MAC1894A04 Tobacco







MAC1894A02 Other substances (e.g., cocaine, heroin)







MAC1894A05 Parenting/family resources





MAC1895 B8 Please specify the topic of interest for preventing mental illness and promoting mental wellness. (Check all that apply) MAC1895A01 Anger management
Checkbox, one-up vertical M Y Skip Logic Group Professional MH illness


MAC1895A02 Bullying prevention







MAC1895A03 Eating disorders







MAC1895A04 Mood disorders







MAC1895A05 PTSD







MAC1895A06 Schizophrenia







MAC1895A07 Stress management







MAC1895A08 Suicide prevention







MAC1895A09 Parenting/family resources





MAC1896 B9 Please specify the topic of interest for trauma. (Check all that apply) MAC1896A01 Grief
Checkbox, one-up vertical M Y Skip Logic Group Professional trauma


MAC1896A02 Physical or sexual abuse







MAC1896A03 Natural disaster







MAC1896A04 Mass violence







MAC1896A05 Post-military deployment





MAC1897 B10 Please specify other information looking for.


Text area, no char limit
N Skip Logic Group Professional other info
MAC1898
Did you find what you were looking for? MAC1898A01 Yes
Drop down, select one S Y
Find info


MAC1898A02 No






MAC1898A03 Partially






MAC1898A04 Still looking




MAC1899
How satisfied were you with the content available? MAC1899A01 Very satisfied
Drop down, select one S Y Skip Logic Group Content satisfaction



MAC1899A02 Somewhat satisfied








MAC1899A03 No opinion








MAC1899A04 Somewhat dissatisfied A







MAC1899A05 Very dissatisfied A




MAC1900 A Please tell us how our products and resources could be improved.


Text area, no char limit
N Skip Logic Group Improve products
MAC1901
What services could this agency provide to better serve you?


Text area, no char limit
N
Other services wanted
MAC1902
Please specify the types of electronic devices you use. (Check all that apply) MAC1902A01 Desktop or laptop computer
Checkbox, one-up vertical M Y
Device type


MAC1902A02 Tablet or e-reader (e.g., iPad, Kindle, Nook)







MAC1902A03 Smartphone (e.g., iPhone or similar devices with web access)







MAC1902A04 Cell phone





The following demographics questions are entirely optional and will be used for statistical purposes only.
MAC1903
What is your gender? MAC1903A01 Female
Drop down, select one S N
Gender


MAC1903A02 Male






MAC1903A03 Prefer not to respond




MAC1904
Please select the category that includes your age. MAC1904A01 17 and under
Drop down, select one S N
Age


MAC1904A02 18 - 24






MAC1904A03 25 - 34






MAC1904A04 35 - 44






MAC1904A05 45 - 54






MAC1904A06 55 - 64






MAC1904A07 65 and over






MAC1904A08 Prefer not to respond




MAC1905
Which of the following best describes the highest level of education you have completed? MAC1905A01 Current middle or high school student
Drop down, select one S N
Education


MAC1905A02 Did not complete high school






MAC1905A03 High school graduate






MAC1905A04 Some college/vocational school






MAC1905A05 College graduate






MAC1905A06 Some postgraduate school






MAC1905A07 Graduate/professional degree






MAC1905A08 MD/PhD






MAC1905A09 Prefer not to respond




new
Where do you live? new United States A Drop down, select one S N Skip Logic Group Location



new U.S. Territories or Possessions B







new International (please specify) C




MAC1906 A Please select your state. MAC1906A01 Alabama
Drop down, select one S N
State


MAC1906A02 Alaska



Skip Logic Group


MAC1906A03 Arizona






MAC1906A04 Arkansas






MAC1906A05 California






MAC1906A06 Colorado






MAC1906A07 Connecticut






MAC1906A08 Delaware






MAC1906A09 Florida






MAC1906A10 Georgia






MAC1906A11 Hawaii






MAC1906A12 Idaho






MAC1906A13 Illinois






MAC1906A14 Indiana






MAC1906A15 Iowa






MAC1906A16 Kansas






MAC1906A17 Kentucky






MAC1906A18 Louisiana






MAC1906A19 Maine






MAC1906A20 Maryland






MAC1906A21 Massachusetts






MAC1906A22 Michigan






MAC1906A23 Minnesota






MAC1906A24 Mississippi






MAC1906A25 Missouri






MAC1906A26 Montana






MAC1906A27 Nebraska






MAC1906A28 Nevada






MAC1906A29 New Hampshire






MAC1906A30 New Jersey






MAC1906A31 New Mexico






MAC1906A32 New York






MAC1906A33 North Carolina






MAC1906A34 North Dakota






MAC1906A35 Ohio






MAC1906A36 Oklahoma






MAC1906A37 Oregon






MAC1906A38 Pennsylvania






MAC1906A39 Rhode Island






MAC1906A40 South Carolina






MAC1906A41 South Dakota






MAC1906A42 Tennessee






MAC1906A43 Texas






MAC1906A44 Utah






MAC1906A45 Vermont






MAC1906A46 Virginia






MAC1906A47 Washington






MAC1906A48 Washington D.C.






MAC1906A49 West Virginia






MAC1906A50 Wisconsin






MAC1906A51 Wyoming






MAC1906A52 Prefer not to respond




new B Please select your place of residence. new American Samoa
Drop down, select one S N Skip Logic Group Territory



new Guam








new Northern Mariana Islands








new Puerto Rico








new U.S. Virgin Islands





new C Please specify your country. new

Text area, 100 character limit
N Skip Logic Group OE_International
MAC1907
Are you living in a: MAC1907A01 Urban area
Drop down, select one S N
Living area


MAC1907A02 Rural area






MAC1907A03 Don't know




MAC1908
How do you describe your ethnicity? MAC1908A01 Hispanic
Drop down, select one S N
Ethnicity


MAC1908A02 Non-Hispanic






MAC1908A03 Prefer not to respond




MAC1909
How do you describe your race? MAC1909A01 American Indian or Alaska Native
Drop down, select one S N
Race


MAC1909A02 Asian or Pacific Islander






MAC1909A03 African American or Black






MAC1909A04 White






MAC1909A05 Other






MAC1909A06 Prefer not to respond





Sheet 4: CQs 4-8-20

Model Instance Name:
red & strike-through: DELETE





SAMHSA Store V2
underlined & italicized: RE-ORDER





MID: YItkJ4B5FR1E0Q5tk49Zow4C

pink: ADDITION





Date: 5/18/16
blue + -->: REWORDING














SAMHSA Store V2 CUSTOM QUESTION LIST

QID
(Group ID)
Skip Logic Label Question Text Answer IDs (DOT ONLY) Answer Choices
(limited to 50 characters)
Skip to Type (select from list) Single or Multi Required
Y/N
Special Instructions CQ Label
MAC1878
How frequently do you visit the SAMHSA Store? MAC1878A01 First time
Drop down, select one S Y
Frequency of visits


MAC1878A02 Daily






MAC1878A03 Weekly






MAC1878A04 Monthly






MAC1878A05 Every few months or less often




MAC1879
What is your primary interest in substance abuse and mental health topics? MAC1879A01 Personal A1-A3 Drop down, select one S Y Skip Logic Group Primary interest


MAC1879A02 Professional B1-B4




MAC1880 A1 For whom are you looking up information and resources? MAC1880A01 Yourself
Radio button, one-up vertical S Y Skip Logic Group Personal info for


MAC1880A02 Family member







MAC1880A03 Friend





MAC1881 A2 What is the age of the person for whom you are seeking resources? MAC1881A01 12 and under
Radio button, one-up vertical S Y Skip Logic Group Personal age


MAC1881A02 13 to 17







MAC1881A03 18 to 24







MAC1881A04 25 to 34







MAC1881A05 35 to 44







MAC1881A06 45 to 54







MAC1881A07 55 to 64







MAC1881A08 65 and older





MAC1882 A3 Are you primarily looking for information on any of the following topics? MAC1882A01 Treatment and recovery A4 Radio button, one-up vertical S Y Skip Logic Group Personal info topic


MAC1882A02 Preventing substance abuse problems A5






MAC1882A03 Preventing mental illness/promoting mental wellness A6






MAC1882A04 Helping someone cope with and recover from a traumatic event A7






MAC1882A05 Other, please specify A8




MAC1883 A4 Please specify the topic of interest for treatment and recovery. (Check all that apply) MAC1883A01 Options for paying for treatment
Checkbox, one-up vertical M Y Skip Logic Group Personal treatment


MAC1883A02 Understanding different types of treatment







MAC1883A03 Identifying a treatment professional or facility







MAC1883A04 Recovery support services (e.g., support groups)







MAC1883A05 Information about specific substances of abuse







MAC1883A06 Information about specific mental illnesses





MAC1884 A5 Please specify the topic of interest for substance abuse prevention. (Check all that apply) MAC1884A01 Alcohol
Checkbox, one-up vertical M Y Skip Logic Group Personal SA prevention



Marijuana







MAC1884A03 Prescription drugs







MAC1884A04 Tobacco







MAC1884A02 Other substances (e.g., cocaine, heroin)





MAC1885 A6 Please specify the topic of interest for preventing mental illness and promoting mental wellness. (Check all that apply) MAC1885A01 Anger management
Checkbox, one-up vertical M Y Skip Logic Group Personal MH illness


MAC1885A02 Anxiety or depression







MAC1885A03 Bullying prevention







MAC1885A04 Eating disorders







MAC1885A05 PTSD







MAC1885A06 Schizophrenia







MAC1885A07 Stress management







MAC1885A08 Suicide prevention





MAC1886 A7 Please specify the topic of interest for trauma recovery. (Check all that apply) MAC1886A01 Death of a loved one
Checkbox, one-up vertical M Y Skip Logic Group Personal trauma


MAC1886A02 Physical or sexual abuse







MAC1886A03 Natural disaster







MAC1886A04 Mass violence







MAC1886A05 Post-military deployment





MAC1887 A8 Please specify other information looking for.


Text area, no char limit
N Skip Logic Group Personal other info
MAC1888 B1 What best describes your organization type? MAC1888A01 Behavioral health treatment facility
Radio button, one-up vertical S Y Skip Logic Group Organization type



Criminal justice/courts







Health insurer







Human resources/employee assistance program







Individual or group private practice







Managed care/insurance company office







Military/veterans group







Nonprofit/community-based organization/coalition






MAC1888A02 Non-residential/out-patient facility






MAC1888A05 Public place/Interacting in community






MAC1888A06 Residential/in-patient facility






MAC1888A08 School/university






MAC1888A10 Other A



NEL0120898 A Please specify your organization.

Text area, no char limit
N Skip Logic Group Organization type Other
MAC1889 B2 For whom are you primarily looking for information and resources? MAC1889A01 Professional education for self/colleagues
Radio button, one-up vertical S Y Skip Logic Group Professional info for


MAC1889A02 Use with patients/clients







MAC1889A03 Use within classroom/youth setting







MAC1889A04 Public awareness campaign/event







MAC1889A05 Other





MAC1890 B3 Which of the following best describes the age of your patients, clients, or students? MAC1890A01 12 and under
Radio button, one-up vertical S Y Skip Logic Group Professional age


MAC1890A02 13 to 17







MAC1890A03 18 to 24







MAC1890A04 25 to 34







MAC1890A05 35 to 44







MAC1890A06 45 to 54







MAC1890A07 55 to 64







MAC1890A08 65 and older





MAC1891 B4 Were you primarily looking for information on any of the following topics? MAC1891A01 Affordable Care Act (e.g., health reform, parity) B5 Radio button, one-up vertical S Y Skip Logic Group Professional info topic


MAC1891A02 Treatment and recovery B6






MAC1891A03 Substance abuse prevention B7






MAC1891A04 Preventing mental illness/promoting mental wellness B8






MAC1891A05 Trauma B9






MAC1891A06 Other, please specify B10




MAC1892 B5 Please specify the topic of interest for Affordable Care Act. (Check all that apply) MAC1892A01 Reimbursement for behavioral health services
Checkbox, one-up vertical M Y Skip Logic Group Professional ACA


MAC1892A02 Enrolling patients/clients in health insurance exchanges or Medicaid/Medicare







MAC1892A03 Other





MAC1893 B6 Please specify the topic of interest for treatment and recovery. (Check all that apply) MAC1893A01 Patient/client educational materials
Checkbox, one-up vertical M Y Skip Logic Group Professional treatment


MAC1893A02 Evidence based practices







MAC1893A03 Information for working with specific populations







MAC1893A04 Information about specific substances of abuse







MAC1893A05 Information about specific mental illnesses





MAC1894 B7 Please specify the topic of interest for substance abuse prevention. (Check all that apply) MAC1894A01 Alcohol
Checkbox, one-up vertical M Y Skip Logic Group Professional SA prevention



Marijuana







MAC1894A03 Prescription drugs







MAC1894A04 Tobacco







MAC1894A02 Other substances (e.g., cocaine, heroin)







MAC1894A05 Parenting/family resources





MAC1895 B8 Please specify the topic of interest for preventing mental illness and promoting mental wellness. (Check all that apply) MAC1895A01 Anger management
Checkbox, one-up vertical M Y Skip Logic Group Professional MH illness


MAC1895A02 Bullying prevention







MAC1895A03 Eating disorders







MAC1895A04 Mood disorders







MAC1895A05 PTSD







MAC1895A06 Schizophrenia







MAC1895A07 Stress management







MAC1895A08 Suicide prevention







MAC1895A09 Parenting/family resources





MAC1896 B9 Please specify the topic of interest for trauma. (Check all that apply) MAC1896A01 Grief
Checkbox, one-up vertical M Y Skip Logic Group Professional trauma


MAC1896A02 Physical or sexual abuse







MAC1896A03 Natural disaster







MAC1896A04 Mass violence







MAC1896A05 Post-military deployment





MAC1897 B10 Please specify other information looking for.


Text area, no char limit
N Skip Logic Group Professional other info
MAC1898
Did you find what you were looking for? MAC1898A01 Yes
Drop down, select one S Y
Find info


MAC1898A02 No






MAC1898A03 Partially






MAC1898A04 Still looking




MAC1899
How satisfied were you with the content available? MAC1899A01 Very satisfied
Drop down, select one S Y Skip Logic Group Content satisfaction



MAC1899A02 Somewhat satisfied








MAC1899A03 No opinion








MAC1899A04 Somewhat dissatisfied A







MAC1899A05 Very dissatisfied A




MAC1900 A Please tell us how our products and resources could be improved.


Text area, no char limit
N Skip Logic Group Improve products
MAC1901
What services could this agency provide to better serve you?


Text area, no char limit
N
Other services wanted
MAC1902
Please specify the types of electronic devices you use. (Check all that apply) MAC1902A01 Desktop or laptop computer
Checkbox, one-up vertical M Y
Device type


MAC1902A02 Tablet or e-reader (e.g., iPad, Kindle, Nook)







MAC1902A03 Smartphone (e.g., iPhone or similar devices with web access)







MAC1902A04 Cell phone





The following demographics questions are entirely optional and will be used for statistical purpose only.
MAC1903
What is your gender? MAC1903A01 Female
Drop down, select one S N
Gender


MAC1903A02 Male






MAC1903A03 Prefer not to respond




MAC1904
Please select the category that includes your age. MAC1904A01 17 and under
Drop down, select one S N
Age


MAC1904A02 18 - 24






MAC1904A03 25 - 34






MAC1904A04 35 - 44






MAC1904A05 45 - 54






MAC1904A06 55 - 64






MAC1904A07 65 and over






MAC1904A08 Prefer not to respond




MAC1905
Which of the following best describes the highest level of education you have completed? MAC1905A01 Current middle or high school student
Drop down, select one S N
Education


MAC1905A02 Did not complete high school






MAC1905A03 High school graduate






MAC1905A04 Some college/vocational school






MAC1905A05 College graduate






MAC1905A06 Some postgraduate school






MAC1905A07 Graduate/professional degree






MAC1905A08 MD/PhD






MAC1905A09 Prefer not to respond




MAC1906
What state do you live in? MAC1906A01 Alabama
Drop down, select one S N
State


MAC1906A02 Alaska






MAC1906A03 Arizona






MAC1906A04 Arkansas






MAC1906A05 California






MAC1906A06 Colorado






MAC1906A07 Connecticut






MAC1906A08 Delaware






MAC1906A09 Florida






MAC1906A10 Georgia






MAC1906A11 Hawaii






MAC1906A12 Idaho






MAC1906A13 Illinois






MAC1906A14 Indiana






MAC1906A15 Iowa






MAC1906A16 Kansas






MAC1906A17 Kentucky






MAC1906A18 Louisiana






MAC1906A19 Maine






MAC1906A20 Maryland






MAC1906A21 Massachusetts






MAC1906A22 Michigan






MAC1906A23 Minnesota






MAC1906A24 Mississippi






MAC1906A25 Missouri






MAC1906A26 Montana






MAC1906A27 Nebraska






MAC1906A28 Nevada






MAC1906A29 New Hampshire






MAC1906A30 New Jersey






MAC1906A31 New Mexico






MAC1906A32 New York






MAC1906A33 North Carolina






MAC1906A34 North Dakota






MAC1906A35 Ohio






MAC1906A36 Oklahoma






MAC1906A37 Oregon






MAC1906A38 Pennsylvania






MAC1906A39 Rhode Island






MAC1906A40 South Carolina






MAC1906A41 South Dakota






MAC1906A42 Tennessee






MAC1906A43 Texas






MAC1906A44 Utah






MAC1906A45 Vermont






MAC1906A46 Virginia






MAC1906A47 Washington






MAC1906A48 Washington D.C.






MAC1906A49 West Virginia






MAC1906A50 Wisconsin






MAC1906A51 Wyoming






MAC1906A52 Prefer not to respond




MAC1907
Are you living in a: MAC1907A01 Urban area
Drop down, select one S N
Living area


MAC1907A02 Rural area






MAC1907A03 Don't know




MAC1908
How do you describe your ethnicity? MAC1908A01 Hispanic
Drop down, select one S N
Ethnicity


MAC1908A02 Non-Hispanic






MAC1908A03 Prefer not to respond




MAC1909
How do you describe your race? MAC1909A01 American Indian or Alaska Native
Drop down, select one S N
Race


MAC1909A02 Asian or Pacific Islander






MAC1909A03 African American or Black






MAC1909A04 White






MAC1909A05 Other






MAC1909A06 Prefer not to respond





Sheet 5: CQs (6-8-16)

Model Instance Name:
red & strike-through: DELETE





SAMHSA Store V2
underlined & italicized: RE-ORDER





MID: YItkJ4B5FR1E0Q5tk49Zow4C

pink: ADDITION





Date: 5/18/16
blue + -->: REWORDING














SAMHSA Store V2 CUSTOM QUESTION LIST

QID
(Group ID)
Skip Logic Label Question Text Answer IDs (DOT ONLY) Answer Choices
(limited to 50 characters)
Skip to Type (select from list) Single or Multi Required
Y/N
Special Instructions CQ Label
MAC1878
How frequently do you visit the SAMHSA Store? MAC1878A01 First time
Drop down, select one S Y
Frequency of visits


MAC1878A02 Daily






MAC1878A03 Weekly






MAC1878A04 Monthly






MAC1878A05 Every few months or less often




MAC1879
What is your primary interest in substance abuse and mental health topics? MAC1879A01 Personal A1-A3 Drop down, select one S Y Skip Logic Group Primary interest


MAC1879A02 Professional B1-B4




MAC1880 A1 For whom are you looking up information and resources? MAC1880A01 Yourself
Radio button, one-up vertical S Y Skip Logic Group Personal info for


MAC1880A02 Family member







MAC1880A03 Friend





MAC1881 A2 What is the age of the person for whom you are seeking resources? MAC1881A01 12 and under
Radio button, one-up vertical S Y Skip Logic Group Personal age


MAC1881A02 13 to 17







MAC1881A03 18 to 24







MAC1881A04 25 to 34







MAC1881A05 35 to 44







MAC1881A06 45 to 54







MAC1881A07 55 to 64







MAC1881A08 65 and older





MAC1882 A3 Are you primarily looking for information on any of the following topics? MAC1882A01 Treatment and recovery A4 Radio button, one-up vertical S Y Skip Logic Group Personal info topic


MAC1882A02 Preventing substance abuse problems A5






MAC1882A03 Preventing mental illness/promoting mental wellness A6






MAC1882A04 Helping someone cope with and recover from a traumatic event A7






MAC1882A05 Other, please specify A8




MAC1883 A4 Please specify the topic of interest for treatment and recovery. (Check all that apply) MAC1883A01 Options for paying for treatment
Checkbox, one-up vertical M Y Skip Logic Group Personal treatment


MAC1883A02 Understanding different types of treatment







MAC1883A03 Identifying a treatment professional or facility







MAC1883A04 Recovery support services (e.g., support groups)







MAC1883A05 Information about specific substances of abuse







MAC1883A06 Information about specific mental illnesses





MAC1884 A5 Please specify the topic of interest for substance abuse prevention. (Check all that apply) MAC1884A01 Alcohol
Checkbox, one-up vertical M Y Skip Logic Group Personal SA prevention



Marijuana







MAC1884A03 Prescription drugs







MAC1884A04 Tobacco







MAC1884A02 Other substances (e.g., cocaine, heroin)





MAC1885 A6 Please specify the topic of interest for preventing mental illness and promoting mental wellness. (Check all that apply) MAC1885A01 Anger management
Checkbox, one-up vertical M Y Skip Logic Group Personal MH illness


MAC1885A02 Anxiety or depression







MAC1885A03 Bullying prevention







MAC1885A04 Eating disorders







MAC1885A05 PTSD







MAC1885A06 Schizophrenia







MAC1885A07 Stress management







MAC1885A08 Suicide prevention





MAC1886 A7 Please specify the topic of interest for trauma recovery. (Check all that apply) MAC1886A01 Death of a loved one
Checkbox, one-up vertical M Y Skip Logic Group Personal trauma


MAC1886A02 Physical or sexual abuse







MAC1886A03 Natural disaster







MAC1886A04 Mass violence







MAC1886A05 Post-military deployment





MAC1887 A8 Please specify other information looking for.


Text area, no char limit
N Skip Logic Group Personal other info
MAC1888 B1 What best describes your organization type? MAC1888A01 Behavioral health treatment facility
Radio button, one-up vertical S Y Skip Logic Group Organization type



Criminal justice/courts







Government office







Health insurer







Human resources/employee assistance program







Individual or group private practice







Managed care/insurance company office







Military/veterans group







Nonprofit/community-based organization/coalition






MAC1888A02 Non-residential/out-patient facility






MAC1888A03







MAC1888A04 Other health care facility (e.g., primary care)






MAC1888A05 Public place/Interacting in community






MAC1888A06 Residential/in-patient facility






MAC1888A08 School/university






MAC1888A10 Other A



A Please specify your organization.

Text area, no char limit
N Skip Logic Group Organization type Other
MAC1889 B2 For whom are you primarily looking for information and resources? MAC1889A01 Professional education for self/colleagues
Radio button, one-up vertical S Y Skip Logic Group Professional info for


MAC1889A02 Use with patients/clients







MAC1889A03 Use within classroom/youth setting







MAC1889A04 Public awareness campaign/event







MAC1889A05 Other





MAC1890 B3 Which of the following best describes the age of your patients, clients, or students? MAC1890A01 12 and under
Radio button, one-up vertical S Y Skip Logic Group Professional age


MAC1890A02 13 to 17







MAC1890A03 18 to 24







MAC1890A04 25 to 34







MAC1890A05 35 to 44







MAC1890A06 45 to 54







MAC1890A07 55 to 64







MAC1890A08 65 and older





MAC1891 B4 Were you primarily looking for information on any of the following topics? MAC1891A01 Affordable Care Act (e.g., health reform, parity) B5 Radio button, one-up vertical S Y Skip Logic Group Professional info topic


MAC1891A02 Treatment and recovery B6






MAC1891A03 Substance abuse prevention B7






MAC1891A04 Preventing mental illness/promoting mental wellness B8






MAC1891A05 Trauma B9






MAC1891A06 Other, please specify B10




MAC1892 B5 Please specify the topic of interest for Affordable Care Act. (Check all that apply) MAC1892A01 Reimbursement for behavioral health services
Checkbox, one-up vertical M Y Skip Logic Group Professional ACA


MAC1892A02 Enrolling patients/clients in health insurance exchanges or Medicaid/Medicare







MAC1892A03 Other





MAC1893 B6 Please specify the topic of interest for treatment and recovery. (Check all that apply) MAC1893A01 Patient/client educational materials
Checkbox, one-up vertical M Y Skip Logic Group Professional treatment


MAC1893A02 Evidence based practices







MAC1893A03 Information for working with specific populations







MAC1893A04 Information about specific substances of abuse







MAC1893A05 Information about specific mental illnesses





MAC1894 B7 Please specify the topic of interest for substance abuse prevention. (Check all that apply) MAC1894A01 Alcohol
Checkbox, one-up vertical M Y Skip Logic Group Professional SA prevention



Marijuana







MAC1894A03 Prescription drugs







MAC1894A04 Tobacco







MAC1894A02 Other substances (e.g., cocaine, heroin)







MAC1894A05 Parenting/family resources





MAC1895 B8 Please specify the topic of interest for preventing mental illness and promoting mental wellness. (Check all that apply) MAC1895A01 Anger management
Checkbox, one-up vertical M Y Skip Logic Group Professional MH illness


MAC1895A02 Bullying prevention







MAC1895A03 Eating disorders







MAC1895A04 Mood disorders







MAC1895A05 PTSD







MAC1895A06 Schizophrenia







MAC1895A07 Stress management







MAC1895A08 Suicide prevention







MAC1895A09 Parenting/family resources





MAC1896 B9 Please specify the topic of interest for trauma. (Check all that apply) MAC1896A01 Grief
Checkbox, one-up vertical M Y Skip Logic Group Professional trauma


MAC1896A02 Physical or sexual abuse







MAC1896A03 Natural disaster







MAC1896A04 Mass violence







MAC1896A05 Post-military deployment





MAC1897 B10 Please specify other information looking for.


Text area, no char limit
N Skip Logic Group Professional other info
MAC1898
Did you find what you were looking for? MAC1898A01 Yes
Drop down, select one S Y
Find info


MAC1898A02 No






MAC1898A03 Partially






MAC1898A04 Still looking




MAC1899
How satisfied were you with the content available? MAC1899A01 Very satisfied
Drop down, select one S Y Skip Logic Group Content satisfaction



MAC1899A02 Somewhat satisfied








MAC1899A03 No opinion








MAC1899A04 Somewhat dissatisfied A







MAC1899A05 Very dissatisfied A




MAC1900 A Please tell us how our products and resources could be improved.


Text area, no char limit
N Skip Logic Group Improve products
MAC1901
What services could this agency provide to better serve you?


Text area, no char limit
N
Other services wanted
MAC1902
Please specify the types of electronic devices you use. (Check all that apply) MAC1902A01 Desktop or laptop computer
Checkbox, one-up vertical M Y
Device type


MAC1902A02 Tablet or e-reader (e.g., iPad, Kindle, Nook)







MAC1902A03 Smartphone (e.g., iPhone or similar devices with web access)







MAC1902A04 Cell phone





The following demographics questions are entirely optional and will be used for statistical purpose only.
MAC1903
What is your gender? MAC1903A01 Female
Drop down, select one S N
Gender


MAC1903A02 Male






MAC1903A03 Prefer not to respond




MAC1904
Please select the category that includes your age. MAC1904A01 17 and under
Drop down, select one S N
Age


MAC1904A02 18 - 24






MAC1904A03 25 - 34






MAC1904A04 35 - 44






MAC1904A05 45 - 54






MAC1904A06 55 - 64






MAC1904A07 65 and over






MAC1904A08 Prefer not to respond




MAC1905
Which of the following best describes the highest level of education you have completed? MAC1905A01 Current middle or high school student
Drop down, select one S N
Education


MAC1905A02 Did not complete high school






MAC1905A03 High school graduate






MAC1905A04 Some college/vocational school






MAC1905A05 College graduate






MAC1905A06 Some postgraduate school






MAC1905A07 Graduate/professional degree






MAC1905A08 MD/PhD






MAC1905A09 Prefer not to respond




MAC1906
What state do you live in? MAC1906A01 Alabama
Drop down, select one S N
State


MAC1906A02 Alaska






MAC1906A03 Arizona






MAC1906A04 Arkansas






MAC1906A05 California






MAC1906A06 Colorado






MAC1906A07 Connecticut






MAC1906A08 Delaware






MAC1906A09 Florida






MAC1906A10 Georgia






MAC1906A11 Hawaii






MAC1906A12 Idaho






MAC1906A13 Illinois






MAC1906A14 Indiana






MAC1906A15 Iowa






MAC1906A16 Kansas






MAC1906A17 Kentucky






MAC1906A18 Louisiana






MAC1906A19 Maine






MAC1906A20 Maryland






MAC1906A21 Massachusetts






MAC1906A22 Michigan






MAC1906A23 Minnesota






MAC1906A24 Mississippi






MAC1906A25 Missouri






MAC1906A26 Montana






MAC1906A27 Nebraska






MAC1906A28 Nevada






MAC1906A29 New Hampshire






MAC1906A30 New Jersey






MAC1906A31 New Mexico






MAC1906A32 New York






MAC1906A33 North Carolina






MAC1906A34 North Dakota






MAC1906A35 Ohio






MAC1906A36 Oklahoma






MAC1906A37 Oregon






MAC1906A38 Pennsylvania






MAC1906A39 Rhode Island






MAC1906A40 South Carolina






MAC1906A41 South Dakota






MAC1906A42 Tennessee






MAC1906A43 Texas






MAC1906A44 Utah






MAC1906A45 Vermont






MAC1906A46 Virginia






MAC1906A47 Washington






MAC1906A48 Washington D.C.






MAC1906A49 West Virginia






MAC1906A50 Wisconsin






MAC1906A51 Wyoming






MAC1906A52 Prefer not to respond




MAC1907
Are you living in a: MAC1907A01 Urban area
Drop down, select one S N
Living area


MAC1907A02 Rural area






MAC1907A03 Don't know




MAC1908
How do you describe your ethnicity? MAC1908A01 Hispanic
Drop down, select one S N
Ethnicity


MAC1908A02 Non-Hispanic






MAC1908A03 Prefer not to respond




MAC1909
How do you describe your race? MAC1909A01 American Indian or Alaska Native
Drop down, select one S N
Race


MAC1909A02 Asian or Pacific Islander






MAC1909A03 African American or Black






MAC1909A04 White






MAC1909A05 Other






MAC1909A06 Prefer not to respond





Sheet 6: CQs (12-17-15)

Model Instance Name:
red & strike-through: DELETE





SAMHSA Store V2
underlined & italicized: RE-ORDER





MID: YItkJ4B5FR1E0Q5tk49Zow4C

pink: ADDITION





Date: 12/15/2015
blue + -->: REWORDING














SAMHSA Store V2 CUSTOM QUESTION LIST
QID
(Group ID)
Skip Logic Label Question Text Answer IDs (DOT ONLY) Answer Choices
(limited to 50 characters)
Skip to Type (select from list) Single or Multi Required
Y/N
Special Instructions CQ Label
MAC1878
How frequently do you visit the SAMHSA Store? MAC1878A01 First time
Drop down, select one S Y
Frequency of visits


MAC1878A02 Daily






MAC1878A03 Weekly






MAC1878A04 Monthly






MAC1878A05 Every few months or less often




MAC1879
What is your primary interest in substance abuse and mental health topics? MAC1879A01 Personal A1-A3 Drop down, select one S Y Skip Logic Group Primary interest


MAC1879A02 Professional B1-B4




MAC1880 A1 For whom are you looking up information and resources? MAC1880A01 Yourself
Radio button, one-up vertical S Y
Personal info for


MAC1880A02 Family member







MAC1880A03 Friend





MAC1881 A2 What is the age of the person for whom you are seeking resources? MAC1881A01 12 and under
Radio button, one-up vertical S Y
Personal age


MAC1881A02 13 to 17







MAC1881A03 18 to 24







MAC1881A04 25 to 34







MAC1881A05 35 to 44







MAC1881A06 45 to 54







MAC1881A07 55 to 64







MAC1881A08 65 and older





MAC1882 A3 Are you primarily looking for information on any of the following topics? MAC1882A01 Treatment and recovery A4 Radio button, one-up vertical S Y
Personal info topic


MAC1882A02 Preventing substance abuse problems A5






MAC1882A03 Preventing mental illness/promoting mental wellness A6






MAC1882A04 Helping someone cope with and recover from a traumatic event A7






MAC1882A05 Other, please specify A8




MAC1883 A4 Please specify the topic of interest for treatment and recovery. (Check all that apply) MAC1883A01 Options for paying for treatment
Checkbox, one-up vertical M Y
Personal treatment


MAC1883A02 Understanding different types of treatment







MAC1883A03 Identifying a treatment professional or facility







MAC1883A04 Recovery support services (e.g., support groups)







MAC1883A05 Information about specific substances of abuse







MAC1883A06 Information about specific mental illnesses





MAC1884 A5 Please specify the topic of interest for substance abuse prevention. (Check all that apply) MAC1884A01 Alcohol
Checkbox, one-up vertical M Y
Personal SA prevention



Marijuana







MAC1884A03 Prescription drugs







MAC1884A04 Tobacco







MAC1884A02 Other substances (e.g., cocaine, heroin)





MAC1885 A6 Please specify the topic of interest for preventing mental illness and promoting mental wellness. (Check all that apply) MAC1885A01 Anger management
Checkbox, one-up vertical M Y
Personal MH illness


MAC1885A02 Anxiety or depression







MAC1885A03 Bullying prevention







MAC1885A04 Eating disorders







MAC1885A05 PTSD







MAC1885A06 Schizophrenia







MAC1885A07 Stress management







MAC1885A08 Suicide prevention





MAC1886 A7 Please specify the topic of interest for trauma recovery. (Check all that apply) MAC1886A01 Death of a loved one
Checkbox, one-up vertical M Y
Personal trauma


MAC1886A02 Physical or sexual abuse







MAC1886A03 Natural disaster







MAC1886A04 Mass violence







MAC1886A05 Post-military deployment





MAC1887 A8 Please specify other information looking for.


Text area, no char limit
N
Personal other info
MAC1888 B1 What best describes your organization type? MAC1888A01 Behavioral health treatment facility
Radio button, one-up vertical S Y
Organization type


MAC1888A02 Other health care facility (e.g., primary care)






MAC1888A03 Government office






MAC1888A04 Nonprofit/community-based organization/coalition






MAC1888A05 School/university






MAC1888A06 Military/veterans group






MAC1888A07 Criminal justice/courts






MAC1888A08 Health insurer






MAC1888A09 Human resources/employee assistance program






MAC1888A10 Other




MAC1889 B2 For whom are you primarily looking for information and resources? MAC1889A01 Professional education for self/colleagues
Radio button, one-up vertical S Y
Professional info for


MAC1889A02 Use with patients/clients







MAC1889A03 Use within classroom/youth setting







MAC1889A04 Public awareness campaign/event







MAC1889A05 Other





MAC1890 B3 Which of the following best describes the age of your patients, clients, or students? MAC1890A01 12 and under
Radio button, one-up vertical S Y
Professional age


MAC1890A02 13 to 17







MAC1890A03 18 to 24







MAC1890A04 25 to 34







MAC1890A05 35 to 44







MAC1890A06 45 to 54







MAC1890A07 55 to 64







MAC1890A08 65 and older





MAC1891 B4 Were you primarily looking for information on any of the following topics? MAC1891A01 Affordable Care Act (e.g., health reform, parity) B5 Radio button, one-up vertical S Y
Professional info topic


MAC1891A02 Treatment and recovery B6






MAC1891A03 Substance abuse prevention B7






MAC1891A04 Preventing mental illness/promoting mental wellness B8






MAC1891A05 Trauma B9






MAC1891A06 Other, please specify B10




MAC1892 B5 Please specify the topic of interest for Affordable Care Act. (Check all that apply) MAC1892A01 Reimbursement for behavioral health services
Checkbox, one-up vertical M Y
Professional ACA


MAC1892A02 Enrolling patients/clients in health insurance exchanges or Medicaid/Medicare







MAC1892A03 Other





MAC1893 B6 Please specify the topic of interest for treatment and recovery. (Check all that apply) MAC1893A01 Patient/client educational materials
Checkbox, one-up vertical M Y
Professional treatment


MAC1893A02 Evidence based practices







MAC1893A03 Information for working with specific populations







MAC1893A04 Information about specific substances of abuse







MAC1893A05 Information about specific mental illnesses





MAC1894 B7 Please specify the topic of interest for substance abuse prevention. (Check all that apply) MAC1894A01 Alcohol
Checkbox, one-up vertical M Y
Professional SA prevention



Marijuana







MAC1894A03 Prescription drugs







MAC1894A04 Tobacco







MAC1894A02 Other substances (e.g., cocaine, heroin)







MAC1894A05 Parenting/family resources





MAC1895 B8 Please specify the topic of interest for preventing mental illness and promoting mental wellness. (Check all that apply) MAC1895A01 Anger management
Checkbox, one-up vertical M Y
Professional MH illness


MAC1895A02 Bullying prevention







MAC1895A03 Eating disorders







MAC1895A04 Mood disorders







MAC1895A05 PTSD







MAC1895A06 Schizophrenia







MAC1895A07 Stress management







MAC1895A08 Suicide prevention







MAC1895A09 Parenting/family resources





MAC1896 B9 Please specify the topic of interest for trauma. (Check all that apply) MAC1896A01 Grief
Checkbox, one-up vertical M Y
Professional trauma


MAC1896A02 Physical or sexual abuse







MAC1896A03 Natural disaster







MAC1896A04 Mass violence







MAC1896A05 Post-military deployment





MAC1897 B10 Please specify other information looking for.


Text area, no char limit
N
Professional other info
MAC1898
Did you find what you were looking for? MAC1898A01 Yes
Drop down, select one S Y
Find info


MAC1898A02 No






MAC1898A03 Partially






MAC1898A04 Still looking




MAC1899
How satisfied were you with the content available? MAC1899A01 Very satisfied
Drop down, select one S Y Skip Logic Group Content satisfaction



MAC1899A02 Somewhat satisfied








MAC1899A03 No opinion








MAC1899A04 Somewhat dissatisfied A







MAC1899A05 Very dissatisfied A




MAC1900 A Please tell us how our products and resources could be improved.


Text area, no char limit
N
Improve products
MAC1901
What services could this agency provide to better serve you?


Text area, no char limit
N
Other services wanted
MAC1902
Please specify the types of electronic devices you use. (Check all that apply) MAC1902A01 Desktop or laptop computer
Checkbox, one-up vertical M Y
Device type


MAC1902A02 Tablet or e-reader (e.g., iPad, Kindle, Nook)







MAC1902A03 Smartphone (e.g., iPhone or similar devices with web access)







MAC1902A04 Cell phone





The following demographics questions are entirely optional and will be used for statistical purpose only.
MAC1903
What is your gender? MAC1903A01 Female
Drop down, select one S N
Gender


MAC1903A02 Male






MAC1903A03 Prefer not to respond




MAC1904
Please select the category that includes your age. MAC1904A01 17 and under
Drop down, select one S N
Age


MAC1904A02 18 - 24






MAC1904A03 25 - 34






MAC1904A04 35 - 44






MAC1904A05 45 - 54






MAC1904A06 55 - 64






MAC1904A07 65 and over






MAC1904A08 Prefer not to respond




MAC1905
Which of the following best describes the highest level of education you have completed? MAC1905A01 Current middle or high school student
Drop down, select one S N
Education


MAC1905A02 Did not complete high school






MAC1905A03 High school graduate






MAC1905A04 Some college/vocational school






MAC1905A05 College graduate






MAC1905A06 Some postgraduate school






MAC1905A07 Graduate/professional degree






MAC1905A08 MD/PhD






MAC1905A09 Prefer not to respond




MAC1906
What state do you live in? MAC1906A01 Alabama
Drop down, select one S N
State


MAC1906A02 Alaska






MAC1906A03 Arizona






MAC1906A04 Arkansas






MAC1906A05 California






MAC1906A06 Colorado






MAC1906A07 Connecticut






MAC1906A08 Delaware






MAC1906A09 Florida






MAC1906A10 Georgia






MAC1906A11 Hawaii






MAC1906A12 Idaho






MAC1906A13 Illinois






MAC1906A14 Indiana






MAC1906A15 Iowa






MAC1906A16 Kansas






MAC1906A17 Kentucky






MAC1906A18 Louisiana






MAC1906A19 Maine






MAC1906A20 Maryland






MAC1906A21 Massachusetts






MAC1906A22 Michigan






MAC1906A23 Minnesota






MAC1906A24 Mississippi






MAC1906A25 Missouri






MAC1906A26 Montana






MAC1906A27 Nebraska






MAC1906A28 Nevada






MAC1906A29 New Hampshire






MAC1906A30 New Jersey






MAC1906A31 New Mexico






MAC1906A32 New York






MAC1906A33 North Carolina






MAC1906A34 North Dakota






MAC1906A35 Ohio






MAC1906A36 Oklahoma






MAC1906A37 Oregon






MAC1906A38 Pennsylvania






MAC1906A39 Rhode Island






MAC1906A40 South Carolina






MAC1906A41 South Dakota






MAC1906A42 Tennessee






MAC1906A43 Texas






MAC1906A44 Utah






MAC1906A45 Vermont






MAC1906A46 Virginia






MAC1906A47 Washington






MAC1906A48 Washington D.C.






MAC1906A49 West Virginia






MAC1906A50 Wisconsin






MAC1906A51 Wyoming






MAC1906A52 Prefer not to respond




MAC1907
Are you living in a: MAC1907A01 Urban area
Drop down, select one S N
Living area


MAC1907A02 Rural area






MAC1907A03 Don't know




MAC1908
How do you describe your ethnicity? MAC1908A01 Hispanic
Drop down, select one S N
Ethnicity


MAC1908A02 Non-Hispanic






MAC1908A03 Prefer not to respond




MAC1909
How do you describe your race? MAC1909A01 American Indian or Alaska Native
Drop down, select one S N
Race


MAC1909A02 Asian or Pacific Islander






MAC1909A03 African American or Black






MAC1909A04 White






MAC1909A05 Other






MAC1909A06 Prefer not to respond





Sheet 7: CQs 7-11-2013

Model Instance Name:
red & strike-through: DELETE





SAMHSA Store V2
underlined & italicized: RE-ORDER





MID: YItkJ4B5FR1E0Q5tk49Zow4C

pink: ADDITION





Date: 7/11/2013
blue + -->: REWORDING














SAMHSA Store V2 CUSTOM QUESTION LIST
QID
(Group ID)
Skip Logic Label Question Text Answer IDs (DOT ONLY) Answer Choices
(limited to 50 characters)
Skip to Type (select from list) Single or Multi Required
Y/N
Special Instructions CQ Label
MAC1878
How frequently do you visit the SAMHSA Store? MAC1878A01 First time
Drop down, select one S Y
Frequency of visits


MAC1878A02 Daily






MAC1878A03 Weekly






MAC1878A04 Monthly






MAC1878A05 Every few months or less often




MAC1879
What is your primary interest in substance abuse and mental health topics? MAC1879A01 Personal A1-A3 Drop down, select one S Y Skip Logic Group Primary interest


MAC1879A02 Professional B1-B4




MAC1880 A1 For whom are you looking up information and resources? MAC1880A01 Yourself
Radio button, one-up vertical S Y
Personal info for


MAC1880A02 Family member







MAC1880A03 Friend





MAC1881 A2 What is the age of the person for whom you are seeking resources? MAC1881A01 12 and under
Radio button, one-up vertical S Y
Personal age


MAC1881A02 13 to 17







MAC1881A03 18 to 24







MAC1881A04 25 to 34







MAC1881A05 35 to 44







MAC1881A06 45 to 54







MAC1881A07 55 to 64







MAC1881A08 65 and older





MAC1882 A3 Are you primarily looking for information on any of the following topics? MAC1882A01 Treatment and recovery A4 Radio button, one-up vertical S Y
Personal info topic


MAC1882A02 Preventing substance abuse problems A5






MAC1882A03 Preventing mental illness/promoting mental wellness A6






MAC1882A04 Helping someone cope with and recover from a traumatic event A7






MAC1882A05 Other, please specify A8




MAC1883 A4 Please specify the topic of interest for treatment and recovery. (Check all that apply) MAC1883A01 Options for paying for treatment
Checkbox, one-up vertical M Y
Personal treatment


MAC1883A02 Understanding different types of treatment







MAC1883A03 Identifying a treatment professional or facility







MAC1883A04 Recovery support services (e.g., support groups)







MAC1883A05 Information about specific substances of abuse







MAC1883A06 Information about specific mental illnesses





MAC1884 A5 Please specify the topic of interest for substance abuse prevention. (Check all that apply) MAC1884A01 Alcohol
Checkbox, one-up vertical M Y
Personal SA prevention


MAC1884A02 Illegal substances (e.g., marijuana, cocaine)







MAC1884A03 Prescription drugs







MAC1884A04 Tobacco





MAC1885 A6 Please specify the topic of interest for preventing mental illness and promoting mental wellness. (Check all that apply) MAC1885A01 Anger management
Checkbox, one-up vertical M Y
Personal MH illness


MAC1885A02 Anxiety or depression







MAC1885A03 Bullying prevention







MAC1885A04 Eating disorders







MAC1885A05 PTSD







MAC1885A06 Schizophrenia







MAC1885A07 Stress management







MAC1885A08 Suicide prevention





MAC1886 A7 Please specify the topic of interest for trauma recovery. (Check all that apply) MAC1886A01 Death of a loved one
Checkbox, one-up vertical M Y
Personal trauma


MAC1886A02 Physical or sexual abuse







MAC1886A03 Natural disaster







MAC1886A04 Mass violence







MAC1886A05 Post-military deployment





MAC1887 A8 Please specify other information looking for.


Text area, no char limit
N
Personal other info
MAC1888 B1 What best describes your organization type? MAC1888A01 Behavioral health treatment facility
Radio button, one-up vertical S Y
Organization type


MAC1888A02 Other health care facility (e.g., primary care)






MAC1888A03 Government office






MAC1888A04 Nonprofit/community-based organization/coalition






MAC1888A05 School/university






MAC1888A06 Military/veterans group






MAC1888A07 Criminal justice/courts






MAC1888A08 Health insurer






MAC1888A09 Human resources/employee assistance program






MAC1888A10 Other




MAC1889 B2 For whom are you primarily looking for information and resources? MAC1889A01 Professional education for self/colleagues
Radio button, one-up vertical S Y
Professional info for


MAC1889A02 Use with patients/clients







MAC1889A03 Use within classroom/youth setting







MAC1889A04 Public awareness campaign/event







MAC1889A05 Other





MAC1890 B3 Which of the following best describes the age of your patients, clients, or students? MAC1890A01 12 and under
Radio button, one-up vertical S Y
Professional age


MAC1890A02 13 to 17







MAC1890A03 18 to 24







MAC1890A04 25 to 34







MAC1890A05 35 to 44







MAC1890A06 45 to 54







MAC1890A07 55 to 64







MAC1890A08 65 and older





MAC1891 B4 Were you primarily looking for information on any of the following topics? MAC1891A01 Affordable Care Act (e.g., health reform, parity) B5 Radio button, one-up vertical S Y
Professional info topic


MAC1891A02 Treatment and recovery B6






MAC1891A03 Substance abuse prevention B7






MAC1891A04 Preventing mental illness/promoting mental wellness B8






MAC1891A05 Trauma B9






MAC1891A06 Other, please specify B10




MAC1892 B5 Please specify the topic of interest for Affordable Care Act. (Check all that apply) MAC1892A01 Reimbursement for behavioral health services
Checkbox, one-up vertical M Y
Professional ACA


MAC1892A02 Enrolling patients/clients in health insurance exchanges or Medicaid/Medicare







MAC1892A03 Other





MAC1893 B6 Please specify the topic of interest for treatment and recovery. (Check all that apply) MAC1893A01 Patient/client educational materials
Checkbox, one-up vertical M Y
Professional treatment


MAC1893A02 Evidence based practices







MAC1893A03 Information for working with specific populations







MAC1893A04 Information about specific substances of abuse







MAC1893A05 Information about specific mental illnesses





MAC1894 B7 Please specify the topic of interest for substance abuse prevention. (Check all that apply) MAC1894A01 Alcohol
Checkbox, one-up vertical M Y
Professional SA prevention


MAC1894A02 Illegal substances (e.g., marijuana, cocaine)







MAC1894A03 Prescription drugs







MAC1894A04 Tobacco







MAC1894A05 Parenting/family resources





MAC1895 B8 Please specify the topic of interest for preventing mental illness and promoting mental wellness. (Check all that apply) MAC1895A01 Anger management
Checkbox, one-up vertical M Y
Professional MH illness


MAC1895A02 Bullying prevention







MAC1895A03 Eating disorders







MAC1895A04 Mood disorders







MAC1895A05 PTSD







MAC1895A06 Schizophrenia







MAC1895A07 Stress management







MAC1895A08 Suicide prevention







MAC1895A09 Parenting/family resources





MAC1896 B9 Please specify the topic of interest for trauma. (Check all that apply) MAC1896A01 Grief
Checkbox, one-up vertical M Y
Professional trauma


MAC1896A02 Physical or sexual abuse







MAC1896A03 Natural disaster







MAC1896A04 Mass violence







MAC1896A05 Post-military deployment





MAC1897 B10 Please specify other information looking for.


Text area, no char limit
N
Professional other info
MAC1898
Did you find what you were looking for? MAC1898A01 Yes
Drop down, select one S Y
Find info


MAC1898A02 No






MAC1898A03 Partially






MAC1898A04 Still looking




MAC1899
How satisfied were you with the content available? MAC1899A01 Very satisfied
Drop down, select one S Y Skip Logic Group Content satisfaction



MAC1899A02 Somewhat satisfied








MAC1899A03 No opinion








MAC1899A04 Somewhat dissatisfied A







MAC1899A05 Very dissatisfied A




MAC1900 A Please tell us how our products and resources could be improved.


Text area, no char limit
N
Improve products
MAC1901
What services could this agency provide to better serve you?


Text area, no char limit
N
Other services wanted
MAC1902
Please specify the types of electronic devices you use. (Check all that apply) MAC1902A01 Desktop or laptop computer
Checkbox, one-up vertical M Y
Device type


MAC1902A02 Tablet or e-reader (e.g., iPad, Kindle, Nook)







MAC1902A03 Smartphone (e.g., iPhone or similar devices with web access)







MAC1902A04 Cell phone





The following demographics questions are entirely optional and will be used for statistical purpose only.
MAC1903
What is your gender? MAC1903A01 Female
Drop down, select one S N
Gender


MAC1903A02 Male






MAC1903A03 Prefer not to respond




MAC1904
Please select the category that includes your age. MAC1904A01 17 and under
Drop down, select one S N
Age


MAC1904A02 18 - 24






MAC1904A03 25 - 34






MAC1904A04 35 - 44






MAC1904A05 45 - 54






MAC1904A06 55 - 64






MAC1904A07 65 and over






MAC1904A08 Prefer not to respond




MAC1905
Which of the following best describes the highest level of education you have completed? MAC1905A01 Current middle or high school student
Drop down, select one S N
Education


MAC1905A02 Did not complete high school






MAC1905A03 High school graduate






MAC1905A04 Some college/vocational school






MAC1905A05 College graduate






MAC1905A06 Some postgraduate school






MAC1905A07 Graduate/professional degree






MAC1905A08 MD/PhD






MAC1905A09 Prefer not to respond




MAC1906
What state do you live in? MAC1906A01 Alabama
Drop down, select one S N
State


MAC1906A02 Alaska






MAC1906A03 Arizona






MAC1906A04 Arkansas






MAC1906A05 California






MAC1906A06 Colorado






MAC1906A07 Connecticut






MAC1906A08 Delaware






MAC1906A09 Florida






MAC1906A10 Georgia






MAC1906A11 Hawaii






MAC1906A12 Idaho






MAC1906A13 Illinois






MAC1906A14 Indiana






MAC1906A15 Iowa






MAC1906A16 Kansas






MAC1906A17 Kentucky






MAC1906A18 Louisiana






MAC1906A19 Maine






MAC1906A20 Maryland






MAC1906A21 Massachusetts






MAC1906A22 Michigan






MAC1906A23 Minnesota






MAC1906A24 Mississippi






MAC1906A25 Missouri






MAC1906A26 Montana






MAC1906A27 Nebraska






MAC1906A28 Nevada






MAC1906A29 New Hampshire






MAC1906A30 New Jersey






MAC1906A31 New Mexico






MAC1906A32 New York






MAC1906A33 North Carolina






MAC1906A34 North Dakota






MAC1906A35 Ohio






MAC1906A36 Oklahoma






MAC1906A37 Oregon






MAC1906A38 Pennsylvania






MAC1906A39 Rhode Island






MAC1906A40 South Carolina






MAC1906A41 South Dakota






MAC1906A42 Tennessee






MAC1906A43 Texas






MAC1906A44 Utah






MAC1906A45 Vermont






MAC1906A46 Virginia






MAC1906A47 Washington






MAC1906A48 Washington D.C.






MAC1906A49 West Virginia






MAC1906A50 Wisconsin






MAC1906A51 Wyoming






MAC1906A52 Prefer not to respond




MAC1907
Are you living in a: MAC1907A01 Urban area
Drop down, select one S N
Living area


MAC1907A02 Rural area






MAC1907A03 Don't know




MAC1908
How do you describe your ethnicity? MAC1908A01 Hispanic
Drop down, select one S N
Ethnicity


MAC1908A02 Non-Hispanic






MAC1908A03 Prefer not to respond




MAC1909
How do you describe your race? MAC1909A01 American Indian or Alaska Native
Drop down, select one S N
Race


MAC1909A02 Asian or Pacific Islander






MAC1909A03 African American or Black






MAC1909A04 White






MAC1909A05 Other






MAC1909A06 Prefer not to respond




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