Form 2 Attachment 2 -- Evaluation Patient Survey

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

Evaluation Patient Survey

On behalf of the MedStar-IMPAQ team, thank you for your interest and willingness to participate in this survey on the [CDS Tool Name]. Your feedback is very important to us! The information you provide is voluntary and will be kept strictly confidential and will not be reported or released in any way that allows identification of respondents. If there is a question you would rather not answer, you can skip it. Your participation in the survey will not affect your care and treatment in any way.

We are not selling anything but are conducting a survey about your experience in using [CDS Tool Name] developed under the funding of the Agency for Healthcare Research and Quality within the U.S. Department of Health and Human Services. We are interested in your experience and we hope to know how we can make the [CDS Tool Name] better for patients like you.

This survey will take 10-15 minutes to complete.

First, we would like to ask some background information.

1. What is your age?

• 18-44

• 45-64

• 65 and older

• Prefer not to answer

2. Which best describes your gender?

• Male

• Female

• Prefer to self-describe [Free text answer]

• Prefer not to answer

3. Are you Hispanic or Latino/Latina?

• Yes

• No

• Prefer not to answer

4. What is your race? Please select one or more.

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or Other Pacific Islander

• White

• Other, please specify [Free text answer]

• Prefer not to answer

Now, we would like to ask you some questions about your decision to start using [CDS TOOL NAME].

5. How did you learn about [CDS TOOL NAME]?

• From my care provider at MedStar Health

• From another staff member at MedStar Health

• In an advertisement in a MedStar Health facility

• From a member of the MedStar Health research team

• From another patient at MedStar Health

• [Other response choices as relevant]

6. What was the main reason you agreed to use [CDS TOOL NAME]?

• [Free text entry]

7. What was your biggest concern about using [CDS TOOL NAME]?

• [Free text entry]

How much do you agree with the following statements?

8. It was easy to get started with [CDS TOOL NAME].

• Strongly agree

• Agree

• Neither agree nor disagree

• Disagree

• Strongly disagree

9. My care provider answered all my questions about [CDS TOOL NAME].

• Strongly agree

• Agree

• Neither agree nor disagree

• Disagree

• Strongly disagree

10. I know how to get technical support for [CDS TOOL NAME].

• Strongly agree

• Agree

• Neither agree nor disagree

• Disagree

• Strongly disagree

11. I am confident that [CDS TOOL NAME] protects my private health information.

• Strongly agree

• Agree

• Neither agree nor disagree

• Disagree

• Strongly disagree

12. [CDS TOOL NAME] is a valuable tool for taking care of my health.

• Strongly agree

• Agree

• Neither agree nor disagree

• Disagree

• Strongly disagree

These next questions ask about your experiences using [CDS TOOL NAME].

13. How often do you use [CDS TOOL NAME]?

• Every day

• A few times a week

• Once a week

• A few times a month

• Once a month

• Less often than once a month

14. How often have you talked with your care provider about alerts or messages in [CDS TOOL NAME]?

• Never

• Once

• A few times

• Most times

• Almost every time

15. How valuable is [CDS TOOL NAME] to you?

• Not at all valuable

• A little valuable

• Very valuable

• Extremely valuable

16. Please rank each of the parts of [CDS TOOL NAME], where 1 is the most useful and 5 is the least useful.

• Your Taper Plan

• Milestones

• Pain Assessment

• Messaging

• Resources and Education

17. Overall, how difficult is it to use [CDS TOOL NAME]?

• Not at all difficult

• A little difficult

• Very difficult

• Extremely difficult

18. Has difficulty with [CDS TOOL NAME] ever prevented you from using it when you wanted to?

• No

• Yes

19. [FOR RESPONDENTS WHO CHOSE “A LITTLE/VERY/EXTREMELY DIFFICULT” FOR Q17] What part or parts of [CDS TOOL NAME] were most difficult to use?

• [Free text entry]

20. How likely are you to keep using [CDS TOOL NAME]?

• Definitely will

• Probably will

• Might or might not

• Probably will not

• Definitely will not

21. How can we improve [CDS TOOL NAME] to make it easier to use?

• [Free text entry]

22. How likely are you to keep using [CDS TOOL NAME] if we made the improvement you mentioned?

• Definitely will

• Probably will

• Might or might not

• Probably will not

• Definitely will not

23. If you plan to keep using [CDS TOOL NAME], what are your reasons for using it?

• [Free text entry]

24. If you don’t plan to keep using [CDS TOOL NAME] or are not sure, what areas do you think need to be improved?

• [Free text entry]

25. Please share any other thoughts you have about [CDS TOOL NAME] with us:

• [Free text entry]

Thank you for completing our survey! Your answers help us improve [CDS TOOL NAME] to help other patients like you.

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 15 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