Form 3 Attachment E: Clinician Survey

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

Attachment C: Clinician Survey

Clinician Survey on App Value and Feasibility
The purpose of this survey is to gather feedback on the Major Depression Outcomes app that you accessed as part
of the ‘Implementation of Harmonized Depression Outcome Measures in a Health System to Support PatientCentered Outcomes Research’ study (NCT04235712). The survey should take 5 minutes or less to complete, and
your participation is voluntary.
Your responses to the survey questions will be used to assess the usefulness of the app and the harmonized
depression outcome measures for informing clinical decision-making and the feasibility of using the app within
your routine workflow. Your responses will be summarized in a report to the funding agency, the Agency for
Healthcare Research and Quality, to help the agency understand the value of the app and the feasibility of
implementation in other care settings. Information that could identify you will not be disclosed unless you have
consented to that disclosure.
*Required

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This survey is authorized under 42 U.S.C. 299a. The confidentiality of your responses to this survey is protected by
Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. Information
that could identify you will not be disclosed unless you have consented to that disclosure. Public reporting burden
for this collection of information is estimated to average 5 minutes per response, the estimated time required to
complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection
of information unless it displays a currently valid OMB control number. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to:
AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 5600 Fishers
Lane, Room #07W42, Rockville, MD 20857

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