Q_SAMHSAStore_Web_ Q_SAMHSAStore_Web_Browse_20160518
E-Government Website Customer Satisfaction Surveys
Q_SAMHSAStore_Web_Browse_20160518.xlsx
Mapping and Questionnaire Documents IA 30839 A0 (SAMHSA)
OMB: 1090-0008
⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1090-0008 can be found here:
Document [xlsx]
Download: xlsx | pdf
Current CQs
CQs (6-8-16)
CQs (12-17-15)
CQs 7-11-2013
Overview
Model QstsCurrent CQs
CQs (6-8-16)
CQs (12-17-15)
CQs 7-11-2013
Sheet 1: Model Qsts
| Model Instance Name: | |||||||||
| 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: | ||||||||||
| 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 3: CQs (6-8-16)
| Model Instance Name: | ||||||||||
| 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 | |||||||||
| MAC1888A03 | ||||||||||
| MAC1888A04 | ||||||||||
| 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 4: CQs (12-17-15)
| Model Instance Name: | ||||||||||
| 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 5: CQs 7-11-2013
| Model Instance Name: | ||||||||||
| 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 | |||||||||
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |
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