CMS-10437.GenericSMTestingItemBank 2024
CMS-10437.GenericSMTestingItemBank 2024.docx
Generic Social Marketing & Consumer Testing Research (CMS-10437)
CMS-10437.GenericSMTestingItemBank 2024
OMB: 0938-1247
Social Marketing & Consumer Testing Item Bank
OMB Number: CMS-10437
Centers for Medicare & Medicaid Services (CMS) Office of Communications, Division of Research April 2024
Questions in this item bank will be used to conduct consumer research to support and improve communication with diverse audiences that are affected by CMS initiatives and programs.
Contents
Example of Study Initiation Request Form 5
Health Insurance Satisfaction 15
Description
Before CMS disseminates program communications and messages to the public and other intended audiences consumer research is undertaken to better understand the target audience. A key feature of this work is developing an understanding of how consumers see the world - the “consumer reality.” Factors such as the age, sex, and ethnic background of participants are important, as are their attitudes, perceptions, values, culture, and knowledge. This understanding of the audience helps CMS craft preliminary versions of messages that aim to convey important characteristics of programs and benefits to consumers and other key target audiences. Additional testing is undertaken to help insure that the messages will be understood and that they will encourage people to take appropriate actions.
Messages are typically tested on dimensions such as awareness, clarity, salience, appeal, and persuasiveness. This allows messages to be tailored to specific audience segments. Communication campaigns using the tailored messages are then launched. The effects of those campaigns are monitored to help gauge the impact of the communications and to identify areas for quality improvement.
The item battery in this package is designed to facilitate such testing by establishing a set of pre- approved generic questions that will allow for the rapid turn-around required for CMS to communicate more effectively with its audiences and assess the impact of communication campaigns. Questions from this Social Marketing & Consumer Research Item Bank will be drawn for use in studies that employ
OMB-approved methods for data collection for key CMS audiences. The methods include telephone interviews, individual or small group in-depth/cognitive interviews, usability testing, focus groups, and online/web-based surveys.
The questions in the Social Marketing & Consumer Research Item Bank are divided into two major categories. Items in the Survey Item Bank are typically employed to identify characteristics of individuals and for structured use in quantitative online or telephone surveys. The following domains are represented:
Attitudes
Awareness
Behaviors
Decision Making
Demographics
Health Insurance Satisfaction
Health Status
Information Sources
Internet Use
Knowledge
Mobile Technology
Perceptions
Screening Questions
Items in the Qualitative Item Bank are typically used in less structured one on one and small group discussion formats. These items are more open ended and are often designed to elicit comments or discussion about specific topics or products. The following domains are represented:
Awareness
Behavior
Knowledge
Perceptions
Preferences
Usability
Sources of Information
General Questions
Activities
Items will be selected to meet the requirements for the specific research undertaken. In a typical study, items from the Demographic and Screening Questions will be used to identify appropriate individuals for the research. Core questions will be drawn from the specific domain categories to reflect the type of information needed from the participants. The relevant health topic, behavior, message, phrase, or organization will be inserted into the standard questions to provide the context for the information collection. Taken together, these will define the information collection instrument for that study. To facilitate monitoring of research undertaken as part of this generic clearance, the following information will be provided to OMB on a “Study Initiation Request Form” prior to study initiation:
Title of the project
Description of the research
Contact for lead researcher
Audience characteristics
Purpose of study
Methods to be used
Sample size
Items to be included
Timeline
Estimated burden hours
Administrative contact for research
An example of the format for this Study Initiation Request Form is provided below.
Example of Study Initiation Request Form
Baseline Survev of Consume rs without Hlealth lnsura nee
DesC11ipltion:
The Centers for Medicare and Medicaid Services wiill be implementing research to assistthe Agency in develloping communication materialls to provide outreach to uninsured individuals. These individuals may be eligible for heilp paying for insuranoe costs through a number of mechanisms. To help identify themes arid issues that are top priority for oommu nirnting uvith these audiences, CMS wi 11oonduct a telephone survey with uninrsured iindiViidual:saiimed at examining their ,cunent state of aiVIJ'arrene.s:s, lmowil,edge, and attitudes about health insurance.
Lead
Researcher:
Office of Communication/IDivisiion of IResearch
,eenters.for Medicare and IMedicaiid Services 7500 Security Blvd
Baltimore, IMD 21244
Hemalgi[email protected] 410-786-2157
Purpose of the Study::
Examin,ecurrent knowlledge, awareness, and attitudes about health iinsurance among uninsur,ed aduIts to as:siist witlh deveilopment of appropriately targ,etedloutr,each messaging.
Sample Size:
We expect to inte:rview 500 consumers. tor this re.search. llhe samp1le will! be provided by Survey Sampling International!as re1pr,es.entative of US adulit consumers. irhe sample draw will be suffici.ent to yield the requiired numbe:r of intervi1ews for assuming a 20'% res:ponse rate,.
As:sumirig a 20% response rate and a 50% eligibillity
rate, we plan to s.ele.ct aIpproximateily 2,100 sampie
,cases. iTimeliimie:
December 1, 20XX-January 10, 20XX
For Infonnatiomi 01r1 tlhis proj;ect pIlea1sie oo:ntact:: Cllarese Astrin, Director
Division of Research/Office of Communications (410),786-5424
Audience Charact,eriistics:
500 uninsured adults, age 21-60, throughout tihe United States
Methods lo be,Used:
The data oollection will be undertaken us1ing CATI based teleiPhone survey methodology.
Items to be l11icluded:
SGl, SG2, IIINIG1, ING3, IING4, ING6, AirGl, ATG2, ATGS, AirG6, ATG7, AWGl, AWG2, AWG5, IBGl, BG2, BG3, BG8 [ Etc.]
Estimated !Burden Hours::
500 participants x 0.25 hours= 125 hours
Survey Item Bank
Attitudes
ATG1. Using a scale from 1 to 7, where 1 means you completely disagree and 7 means you completely agree, how would you rate each of the following statements <STATEMENTS RELATED TO TOPIC, INCLUDING:>
Someone else takes care of health care issues so I don’t really need to
It is very important for me to be informed about health issues
I have other people I can always turn to if I need help
I’m concerned about not being able to pay for healthcare
I have a financial plan that includes funding for future healthcare costs
I don’t think much about my health
People often ask me for advice on healthcare issues
I’m very interested in <TOPIC OF RESEARCH>
ATG2. Do you think you will be better or worse off under <PROGRAM OR INITIATIVE EX: THE NEW HEALTH CARE LAW>, or do you think it won’t make much difference?
Better off
Worse off
No difference
DK
REF
ATG3. Under <PROGRAM OR INITIATIVE EX: THE NEW HEALTH CARE LAW>, do you think <TOPICS OF IMPACT EX: YOUR ABILITY TO GET AND KEEP HEALTH INSURANCE, THE COST OF YOUR HEALTH
INSURANCE, WILL GET BETTER, THE QUALITY OF YOUR HEALTH CARE> worse, or stay about the same?
Get better
Stay about the same
Get worse
DK
REF
ATG4. Would you say that changes due to <PROGRAM OR INITIATIVE EX: THE NEW HEALTH CARE LAW> have made your impression of <TOPIC OF IMPACT EX: THE HEALTH INSURANCE MARKETPLACE, MEDICARE, MEDICAID, CHIP> more or less favorable?
Much more favorable
Somewhat more favorable
Stayed about the same
Somewhat less favorable
Much less favorable
DK
REF
ATG5. How do you feel <PROGRAM OR INITIATIVE EX: THE HEALTHCARE LAW>will impact your <TOPICS OF IMPACT EX: YOUR ABILITY TO GET AND KEEP HEALTH INSURANCE, THE COST OF YOUR HEALTH
INSURANCE >? Do you feel it will have a:
Positive impact
No impact at all
Negative impact
DK
REF
ATG6. Thinking about the future of <TOPIC EX: HEALTHCARE, MEDICARE> do you think things are becoming more positive, negative, or do you think things will stay about the same?
More positive
More negative
Stay about the same
DK
REF
ATG7. Overall, would you say that your opinion of <TOPIC EX: HEALTHCARE, MEDICARE> is favorable or unfavorable/positive or negative?
Very favorable/positive
Somewhat favorable/positive
Somewhat unfavorable/negative
Very unfavorable/negative
DK
REF
Awareness
AWG1. How much attention do you pay to news about <TOPIC or INITIATIVE EX: HEALTHCARE ISSUES, PREVENTION, OPEN ENROLLMENT, HEALTHCARE LAW, HEALTH INSURANCE MARKETPLACE>?
A lot
Some
A little
None
DK
REF
AWG2. <TIMEFRAME EX: EVER, PAST 30 DAYS> have you seen, heard, or ready anything about <ITEM EX: TERM, WEBSITE, INITIATIVE>?
Yes
No
DK
REF
AWG2A. Can you briefly tell me what you saw, read, or heard? (OPEN END) AWG2B. Was that in an advertisement, a news story, or both?
Advertisement
News story
Both
DK
REF
AWG3. Where did you see, hear, or read about <ITEM EX: TERM, WEBSITE, INITIATIVE>? (OPEN END)
AWG4. Would you say that what you saw, read, or heard about <ITEM EX: TERM, WEBSITE, INITIATIVE> was positive, negative, or neutral?
Positive
Neutral
Negative
DK
REF
AWG5. <TIMEFRAME EX: IN THE PAST 30 DAYS, IN THE PAST YEAR> where have you seen, heard or read anything about <TOPIC EX: OPEN ENROLLMENT, HEALTH INSURANCE MARKETPLACE, PREVENTIVE HEALTH CARE> on…
Television
Radio
Newspaper
Magazine
Internet
Poster or billboard
In the mail
Other (Specify)
Have not seen anything
AWG6. I am going to describe an <ITEM EX: ADVERTISEMENT, WEBSITE, MATERIAL> that you may have seen within <TIMEFRAME>. <DESCRIPTION OF ITEM>. Do you recall seeing or hearing this <ITEM> within <TIMEFRAME>?
Yes
No
REF
DK
AWG7. There are special <LEVEL EX: NATIONAL, LOCAL, STATEWIDE> toll-free telephone numbers for you to call if you have questions about <TOPIC OR INITIATIVE EX: MEDICARE OPEN ENROLLMENT, THE HEALTH INSURANCE MARKETPLACE, MEDICARE FRAUD>. Before today, did you know that this phone numbers exists?
Behaviors
BG1. <TIMEFRAME EX: IN THE PAST 30 DAYS, IN THE PAST YEAR, DURING THE TIME YOU HAVE BEEN UNINSURED> Have you <BEHAVIORS ASSOCIATED WITH RESEARCHING AND PURCHASING INSURANCE, INCLUDING:>
Considered buying health insurance
Attempted to purchase health insurance
Researched available health insurance plans
Contacted an <AGENT/BROKER/INSURER> to help you to find health insurance
Inquired about Medicaid or other government health insurance programs
Shopped online for health insurance
SCALE:
Yes
No
DK
REF
BG2. How many different prescription medicines do you take on a regular basis, if any?
None
1 to 2 a day
3 to 5 a day
6 or more a day
1 to 2 a week
3 to 5 a week
6 or more a week
DK
REF
BG3. How often do you <HEALTH BEHAVIOR EX: TAKE A LIST OF MEDICATIONS TO THE DOCTOR, TAKE A LIST OF QUESITONS TO THE DOCTOR, VIST THE DOCTOR, GET PREVENTIVE CARE>?
Always
Usually
Sometimes
Never
Not applicable
DK
REF
BG5. <TIMEFRAME EX: IN THE PAST 30 DAYS, IN THE PAST YEAR, DURING THE TIME YOU HAVE BEEN UNINSURED>have you visited <WEBSITE or WEB TOOL EX: HEALTHCARE.GOV, HEALTHINSURANCENOW.GOV>?
Yes
No
DK
REF
BG6. <TIMEFRAME EX: IN THE PAST 30 DAYS, IN THE PAST YEAR, DURING THE TIME YOU HAVE BEEN UNINSURED> have you used <WEBSITE or WEB TOOL EX: HEALTHCARE.GOV, HEALTHINSURANCENOW.GOV>?
Yes
No
DK
REF
BG6A. What information were you looking for when you used <WEBSITE>? (OPEN ENDED) BG6B. Did you get the information you needed from <WEBSITE>?
Yes
No
DK
REF
BG7. <TIMEFRAME EX: IN THE PAST 30 DAYS, IN THE PAST YEAR, DURING THE TIME YOU HAVE BEEN UNINSURED> have you called/used <SOURCE/HOTLINE OR HELP NUMBER EX: 1-800-MEDICARE, SHIP COUNSELOR, HEALTH INSURANCE MARKETPLACE COUNSELOR> to get help?
Yes
No
REF
DK
BG7A. Thinking about the most recent call you made to this number, what was the reason you called? (OPEN ENDED)
BG6B. Did you get the information you needed from <SOURCE/HOTLINE>?
Yes
No
DK
REF
BG8. How likely is it that you will <ACTIVITY ASSOCIATED WITH TOPIC OR INITIATIVE EX: APPLY FOR EXTRA HELP, USE WEBSITE, ASK ABOUT PREVENTIVE TESTS>
Very likely
Somewhat likely
Not very likely
Not at all likely
BG9. As a result of hearing about <TOPIC OR INITIATIVE>, what, if any, action did you take? (OPEN END)
BG10. Have you <TIMEFRAME EX: EVER, PAST 30 DAYS> <ACCESSED EX: VIEWED, DOWNLOADED, RECEIVED> <RESOURCE EX: HANDBOOKS, FACT SHEETS, CONSUMER NOTICES, WEBSITES>?
Yes
No
DK
REF
BG11. When researching/selecting health insurance for <UNIT: SELF, CHILD, EMPLOYEES> do you use/have you used/do you plan to use <RESOURCE EX: WEBSITE, BROKER, AGENT>?
Yes
No
DK
REF
BP1. Does your practice use <ITEM EX: AN ELECTRONIC HEALTH RECORD (EHR)>?
Yes
No
DK
REF
BP2. Do you communicate with patients via (MODE OF COMMUNICATION EX: EMAIL, TEXT, PHR)?
Yes
No
BP3. What percentage of your patients do you communicate with via (MODE OF COMMUNICATION EX: EMAIL, TEXT, PHR)? (OPEN ENDED)
Decision Making
DMG1. When it comes to <TOPIC>, do you usually make decisions on your own, with someone else’s help, or do you rely on someone else to make those decisions for you?
[IF NECESSARY, READ LIST TO CLARIFY.]
I make those decisions on my own without talking to anyone else
I make those decisions on my own, but talk with others about it
I make those decisions with someone else’s help
I rely on someone else to make those decisions for me
DK
REF
DMG2. Who usually helps you to make (or makes) your <TOPIC> decisions? (OPEN ENDED)
DMG3. How long have you used <SOURCE OF ASSISTANCE EX: BROKER, FAMILY MEMBER, DOCTOR> to
help you with <TOPIC>? (OPEN END)
DMG4. Have you ever heard of <TERM EX: AFFORDABLE CARE ACT, HEALTH INSURANCE MARKETPLACE, ELECTRONIC HEALTH RECORD>?
DMG4A. You mentioned that you have heard of <TERM>. Which of the following best describes your level of<CHARACTERISTIC EX: FAMILIARITY, ACTIVITY, INTEREST, INTENT TO PERFORM> with <TERM>.
<SCALE ITEMS TO ASSESS STAGE OF READINESS EX:>
I have heard the term, but do not know much more about it
I have read or heard something about it and know some details
I have discussed the idea of doing <ACTIVITY RELATED TO TERM>
I am actively considering doing <ACTIVITY RELATED TO TERM>
I am in the process of starting <ACTIVITY RELATED TO TERM>
Demographics
DG1. What is your gender? (OPEN ENDED)
DG2. In what year were you born/What is your current age? (OPEN ENDED)
DG3. Are you Hispanic, Latino/a, or Spanish origin? (One or more categories may be selected)
No, not of Hispanic, Latino/a, or Spanish origin
Yes, Mexican, Mexican American, Chicano/a
Yes, Puerto Rican
Yes, Cuban
Yes, Another Hispanic, Latino/a or Spanish origin (Specify)
DG4. What is your race?
White
Black or African American
American Indian or Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian (Specify)
Guamanian or Chamorro
Samoan
Other Pacific Islander (Specify)
DG5. What is the highest level of education you have completed?
Less than high school
High school graduate
Some college
College graduate
Post graduate
DK
REF
DG6. What is your marital status?
Single, never married
Married
In a committed relationship
Living with a partner
Separated
Divorced
Widowed
REF
DK
DG7. Including you, how many people live in your household? (OPEN END)
DG8. How many children under the age of 18 live in your household? (OPEN END)
DG8A. Are you currently pregnant?
Yes
No
DK
REF
DG9. What is your current employment status?
Employed full time
Employed part time
Retired
Unemployed <and not looking/and looking>
Not in the labor force (student, homemaker, etc.)
Other (Specify)
DK
REF
DG10. What is your household’s total annual income before taxes? <PROVIDE RANGES, SUCH AS>:
$0-14,999
$15,000-24,999
$25,000-34,999
$35,000-49,999
$50,000-74,999
$75,000-99,999
100,000-149,999
$150,000 or more
DK
REF
DG11. In what state do you <RESIDE, DO BUSINESS, PRACTICE TRADE OR PROFESSION>? (OPEN END)
DG12. What is the zip code of your primary <RESIDENCE, OFFICE>? (OPEN END) DP1. What is your area of medical specialization? (OPEN ENDED)
DP2.Which of the following best describes your primary work environment;
Hospital
Emergency room
Clinic
Office
Field
Academic
Research
Home or telecommute
Other (Specify)
Health Insurance Satisfaction
ISG1. How satisfied would you say you are with <INSURANCE TOPIC EX: YOUR CURRENT HEALTH INSURANCE SITUATION, THE INSURANCE YOU HAVE FOR DOCTOR AND HOSPITAL COVERAGE, THE INSURANCE YOU HAVE FOR PRESCRIPTION DRUG COVERAGE, INSURANCE PLANS AVAILABLE FOR YOUR BUSINESS, COVERAGE FOR YOUR PATIENTS’ NEEDS>?
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
DK
REF
Health Status
HSG1. Do < HEALTH INSURANCE UNIT EX: YOU, YOUR CHILDREN, YOUR HOUSEHOLD> have any
disabilities?
Yes
No
DK
REF
HSG2. Do < HEALTH INSURANCE UNIT EX: YOU, YOUR CHILDREN, YOUR HOUSEHOLD> have a chronic
illness or health condition?
Yes
No
DK
REF
HSG3. How does your condition affect your ability to <FUNCTION EX: WALK, SEE, HEAR>?
Does not affect my ability
Has some effect on my ability
Affects my ability a lot
DK
REF
HSG3. How would you rate your overall health?
Excellent
Very good
Good
Fair
Poor
Very poor
HSG4. <TIMEFRAME EX: DURING THE PAST 12 MONTHS/30 DAYS> how many times have you
<MEDICAL SERVICE UTILIZATION EX: VISITED A DOCTOR OR OTHER HEALTH PROFESSIONAL, NOT COUNTING OVERNIGHT HOSPITAL VISITS, BEEN HOSPITALIZED OVERNIGHT, BEEN IN A NURSING FACILIT>? (OPEN ENDED)
HSG5. <TIMEFRAM EX: DURING THE PAST 12 MONTHS, IN PAST 30 DAYS> How would you rate your
overall quality of life?
Information Sources
ISG1. Have you ever looked for information on health topics like <HEALTH TOPIC EX: MANAGING ONGOING CONDITIONS LIKE PAIN, ARTHRITIS, OR DIABETES, HEALTHCARE QUALITY INFORMATION, THE NEW HEALTH CARE LAW, THE AFFORDABLE CARE ACT, STAYING HEALTHY AND PREVENTING DISEASE, HEALTH AND WELLNESS, HEALTH INSURANCE>?
Yes
No
DK
REF
ISG2. Where <TIMEFRAME EX: IS THE FIRST PLACE YOU WOULD GO, DO YOU USUALLY GO> to find
information on topics like <HEALTH TOPIC EX: MANAGING ONGOING CONDITIONS LIKE PAIN, ARTHRITIS, OR DIABETES; HEALTHCARE QUALITY INFORMATION, THE NEW HEALTH CARE LAW; THE AFFORDABLE CARE ACT; STAYING HEALTHY AND PREVENTING DISEASE; HEALTH AND WELLNESS; HEALTH INSURANCE>?
The internet
My doctor or health care provider
Family or friends
<HEALTH PLAN LITERATURE EX: MEDICARE & YOU HANDBOOK, INSURANCE NOTICES, EXPLANATIONS OF BENEFITS>
The library
The pharmacist
A <ORGANIZATION EX: LOCAL, GOVERNMENT, CONSUMER, COMMUNITY> like <
ORGANIZATION EX: SHIP COUNSELOR, AARP, STATE DEPARTMENT ON HEALTH>
An insurance agent or broker
<SPECIFIC WEBSITE EX: HEATHCARE.GOV>
<NEWS MEDIA EX: NEWSPAPER, MAGAZINE, TELEVISION, RADIO>
DK
REF
ISG3. How often do you use <SOURCES OF INFORMATION> when you have a question about <TOPIC OR INITIATIVE>?
Often
Sometimes
Occasionally
Rarely
Never
DK
REF
ISG4. What health insurance plan features are most important to you when comparing health plans? (Rank features below on a comparative scale)
Cost of the premium
Deductible amount
Co-payments
Co-insurance
Out of Pocket Maximum
Types of treatment or services covered
What prescription drugs are covered
Quality of medical care provided by the plan
Quality of the service provided by the plan
Don’t recall what I compared
Other (Specify)
ISG4A. Where would you go to find this information? <LIST SOURCES EX: WEBSITE, BROKER, MEDICARE & YOU HANDBOOK>
ISG5. How do you prefer to receive information about <TOPIC OR INITIATIVE EX: HEALTH INSURANCE, PREVENTION>?
Cell phone call or voicemail
Search engines
Email
Wiki
YouTube, videos
Text messages
Social networking sites
Blogs
Podcasts
US mail
Other (Specify)
ISG6. How much do agree or disagree with the following statements: I trust <INFORMATION SOURCE EX: BROKERS> to <CHARACTERISTIC OF TOPIC or ITEM EX: GIVE ME ACCURATE INFORMATION ABOUT THE COST OF INSURANCE PLANS>.
Strongly agree
Somewhat agree
Somewhat disagree
Strongly Disagree
DK
REF
Health Insurance Status
ING1. Do <HEALTH INSURANCE UNIT EX: YOU, YOUR CHILDREN, YOUR HOUSEHOLD> currently have
health insurance coverage?
Yes
No
DK
REF
ING2. How do < HEALTH INSURANCE UNIT EX: YOU, YOUR CHILDREN, YOUR HOUSEHOLD> currently
get health insurance to cover your hospital expenses or doctor’s visits? Do you get it through
<POTENTIAL WAYS OF GETTING HEALTH INSURANCE, INCLUDING>:
Current or former employer
Spouse or partner’s current or former employer
Parent’s current or former employer
A plan you purchase on your own directly from a health insurance company
A COBRA health insurance plan
Medicare and a supplemental insurance policy, sometimes called Medigap
A Medicare HMO or PPO plan, also known as Medicare Advantage, where you have to see a doctor from the plan’s list
Medicare plus employer or retiree coverage
Medicaid or State Assistance
VA or Veterans’ Health Insurance
Tricare
Indian Health Services
Other (specify)
A combination (specify)
DK
REF
ING3. For how long have < HEALTH INSURANCE UNIT EX: YOU, YOUR CHILDREN, YOUR HOUSEHOLD>
been without/had/offered health insurance?
Less than 6 months
6 months to less than one year
One year to less than two years
More than two years
Never had health insurance
DK
REF
ING4. What is the main reason < HEALTH INSURANCE UNIT EX: YOU, YOUR CHILDREN, YOUR
HOUSEHOLD, BUSINESS> do not have insurance? (OPEN ENDED)
ING5. Do < HEALTH INSURANCE UNIT EX: YOU, YOUR CHILDREN, YOUR HOUSEHOLD> have an
insurance plan or insurance coverage that pays for your prescription medications?
Yes
No
DK
REF
ING6. Did < HEALTH INSURANCE UNIT EX: YOU, YOUR CHILDREN, YOUR HOUSEHOLD> sign up for
<TYPE OF HEALTH OR PRESCRIPTION DRUG PLAN EX: ONE OF THE MEDICARE PRESCRIPTION DRUG PLANS, ALSO KNOWN AS MEDICARE PART D>?
Yes
No
DK
REF
ING7. Here is a list of the kinds of insurance and health plans that some people have that help pay for their prescription drugs. Please tell me which you have:
Medigap, or Medicare Supplemental insurance
A Medicare Advantage plan
A health insurance plan that also covers prescription drugs
A standalone prescription drug plan
An HMO
A PPO
Employer, Union, or retiree health insurance
VA or Veterans benefits
Military retiree benefits or TRICARE
Other (Specify)
DK
REF
ING8. Did you purchase your <INSURNCE TYPE EX: PRESCRIPTION DRUG INSURANCE> directly from an insurance company or is that something you pay for or receive as a benefit from your employer or union?
From an insurance company
Through employer or union
Other (Specify)
DK
REF
ING9. Does your insurance plan allow you to go to any doctor you choose or do you have to pick from a list of doctors provided by their insurance company?
Can go to any doctor
Can go to any doctor, but might have to pay more if not on list
Must pick doctor from a list
DK
REF
ING10. How do <UNIT: YOU, CHILD, EMPLOYEES> currently get health insurance? (OPEN END)
INBO1. Do you currently provide health insurance for the employees in your company?
Yes – All
Yes – Some
No
DK
REF
INBO2. What was/were the main decision factor(s) for whether to provide health insurance for the employees in your company? (OPEN END)
INBO3. What percent of the premium for the cost of insurance do you pay for your employees? (OPEN END)
Internet Use
IUG1. Do you have access to the Internet, either on your own or with someone else’s help?
Yes
No
DK
REF
IUG2. Do you require the help of someone else in order to access the internet?
Yes
No
DK
REF
IUG3. Do you personally use the Internet?
Use Internet
Do not use internet
DK
REF
IUG4. How often do you access the internet on your own or with someone else’s help? [READ LIST]
Daily
Almost daily
3 to 5 days a week
1 to 2 days a week
Once every few weeks
A few times a year
Don’t have internet access/don’t use the internet
REF
DK
IUG5. Where you do you usually access the internet?
Home
Work
Home and work
Other (Specify)
Do not use internet
DK
REF
IUG6. What type of internet connection do you have at <LOCATION EX: HOME/WORK/WHERE YOU NORMALLY ACCESS THE INTERNET>?
Cable
DSL
Broadband
Dial-up
Wireless (Wi-Fi)
Satellite
Other (Specify)
I do not have internet at <LOCATION, E.G., home>
DK
REF
IUG8. When you use the Internet, do you use a (Select all that apply)
A personal desktop or laptop computer
An iPad or other tablet computer
A smart cell phone, like an iPhone or Blackberry
Other [please specify):
IUG9. How do you use the Internet? <LIST OF INTERNET ACTIVITIES, INCLUDING>:
To send and receive email
To search for information in general
To search for information about health and wellness
To shop
To manage credit cards, banking, or saving accounts
To manage investments
To manage health insurance
To watch videos or play games
To connect with people on social networking sites like Facebook and LinkedIn
Other (specify):
IUG14. Do you participate in any sort of online social networking?
Yes
No
DK
REF
IUG15. Which of the following social networking sites do you use? <LIST OF SOCIAL NETWORKING SITES, INCLUDING>:
Facebook
Pinterest
Twitter
Google +
Foursquare
Other (Specify)
None of these
IUG16. Do you use the internet to view photos or videos through sites like YouTube and Flickr?
Yes
No
DK
REF
IUG17. Have you ever used the internet to find out information about <TOPIC OF INTEREST – EX: HEALTH INSURANCE PLANS, PREVENTION, HEALTH INSURANCE EXCHANGES, MEDICARE, MEDICAID>?
Yes
No
DK
REF
IUG18. Have you (or someone who helps you) <TIMEFRAME EX: EVER, RECENTLY, LAST WEEK> used the internet to <BEHAVIOR EX: COMPARE YOUR HEALTH INSURANCE PLAN TO OTHER PLANS>?
Yes
No
DK
REF
IUG21. Do you use the internet to <ACTIVITIES THAT REQUIRE TRANSACTIONS EX: BANK ONLINE, SHOP ONLINE, MAKE TRAVEL RESERVATIONS ONLINE>?
Yes
No
DK
REF
IUG22. On a scale of 1 to 7, where 1 means not at all comfortable, and a 7 means very comfortable, how comfortable would you be entering the following information into a secure online server for the purposes of enrolling in health insurance <POTENTIALLY SENSITIVE INFORMATION, INCLUDING>:
Full name
Date of birth
Social security number
Income
Children’s full names
Children’s dates of birth
Children’s social security numbers
Immigration status
Knowledge
KG1. As you might know, <TOPIC OR PROGRAM EX: HEALTH CARE REFORM LEGISLATION WAS SIGNED
INTO LAW>. Do you feel you have enough information about < TOPIC OR PROGRAM > to understand how it will impact you personally?
Yes, have enough information
No, don’t have enough information
DK
REF
KG2. Using the following scale, to what extent do you agree or disagree with the following statement: I have the information and resources I need to <TOPIC OF OURTREACH AND EDUCATION EX: MAKE AN INFORMED COMPARISON AMONG DIFFERENT HEALTH INSURANCE PLAN CHOICES, KNOW WHETHER I AM ELIGIBLE FOR FINANCIAL ASSISTANCE TO HELP PAY FOR MY HEALTH INSURANCE>.
Completely agree
Somewhat agree
Somewhat disagree
Completely disagree
DK
REF
KG3. <BREIF DESCRIPTION OF WEBSITE, TOOL, INITIATIVE> To your knowledge, does a <WEBSITE,
TOOL, INITIATIVE> like this exist?
Yes
No
DK
REF
KG3A. [If YES] What is the name of that <WEBSITE, TOOL, INITIATIVE>? [Open End]
KG4. How likely do you think it is that < UNIT EX: YOU, YOUR CHILD, YOUR EMPLOYEES> would be eligible for <INITIATIVE or TOPIC EX: EXTRA HELP, MEDICARE/MEDICAID/CHIP>
Very likely
Somewhat likely
Not very likely
Not at all likely
DK
REF
KG5. Using the following scale, to what extent do you agree or disagree with the following statement: I have the information and resources I need to make an informed comparison among different
<HEALTH/HEALTH INSURANCE/INITIATIVE RELATED OPTIONS OR CHOICES>.
Completely agree
Somewhat agree
Somewhat disagree
Completely disagree
DK
REF
KG6. Can you provide a brief definition of <TERM> for me? (OPEN END)
KG7. Please tell me if the following statement is true or false/accurate or inaccurate <STATEMENT EX: EACH YEAR, MEDICARE HAS AN OPEN ENROLLMENT PERIOD WHEN PEOPLE ON MEDICARE CAN DECIDE TO MAKE CHANGES TO THEIR INSURANCE COVERAGE AND SWITCH TO A DIFFERENT PLAN>.
True/Accurate
False/Inaccurate
DK
REF
KG8. I am going to read you a description of <ITEM EX: INITIATIVE, TOOL, MATERIAL>, and I’d like for you to tell me whether you think it already exists, is likely to exist within the next <TIMEFRAME>, is not likely to exist within the next <TIMEFRAME>.
Already in place
Likely to be in place in <TIMEFRAME>
Unlikely to be in place in <TIMEFRAME>
Mobile Technology
MTG1. Do you own a <TECH DEVICE EX: SMARTPHONE, COMPUTER, TABLET>?
Yes
No
DK
REF
MTG2. Do you use text messaging?
Yes
No
DK
REF
MTG3. <HOW OFTEN DO YOU/DO YOU> use a <TECH DEVICE EX: SMARTPHONE, COMPUTER, TABLET>
to access the internet?
Yes/Very frequently
Somewhat frequently
Somewhat infrequently
Very infrequently
No/Never
DK
REF
MTG3. Do use smart phone applications (apps) to <PERFORM ACTIVITIES EX: SHOP, BROWSE THE INTERNET, BANK, ETC.> using your phone?
Yes
No
DK
REF
MTG4. What kind/brand of <TECH DEVICE EX: SMARTPHONE, COMPUTER, TABLET> do you own? (OPEN END)
Perceptions
PG1. How difficult do you think it is (or would be) to <PERFORM ACTION EX: FIND A HEALTHPLAN THAT IS RIGHT FOR YOU, COMPARE HEALTH PLANS, KNOW WHAT PREVENTIVE TESTS YOU NEED>?
Very easy
Somewhat easy
Somewhat difficult
Very difficult
DK
REF
PG2. What, if anything, makes <BEHAVIOR EX: THE PROCESS OF FINDING AND CHOOSING HEALTH INSURANCE, COMPARING HEALTH PLANS> difficult? (OPEN END)
PG3. Using a scale of 1 to 7, where 1 means not at all important and 7 means very important, how important are each of the following when making your health insurance plan choices <LIST OF CONSIDERATIONS, INCLUDING:>?
The monthly amount you pay for the plan (the premium)
Out-of-pocket costs you pay when you use the plan (co-pay, coinsurance, and deductible)
The cost of prescription drugs
An expert rating of how well the plan keeps people healthy
An expert rating of patient satisfaction with the plan
Coverage of tests and screenings to diagnose and prevent disease (e.g., annual physicals, mammograms)
Coverage to help you when you are sick
The doctors and hospitals included in the plan
Maximum amount you would pay each year, not including the monthly premium.
PG4. Now I am going to read you a list of things that may be included on a website designed to help people find and compare health insurance plans. Please tell me how helpful you think each of these would be to you personally <CHARACTERISTICS OF HEALTH INSURANCE MARKETPLACE, INCLUDING>:
The website offers unbiased information about health insurance
The website allows you to review and compare health insurance plans from many companies in one place
The website uses a simple ranking system that shows which plans offer more comprehensive coverage
The website offers information about what each plan covers and how much each plan costs
The website allows you to sort health plans by different criteria, such the size of the premiums, the cost of co-pays, and total out-of-pocket expenditures
The website allows you to easily determine if you qualify for government assistance to help pay for your health insurance
The website allows you to easily determine if you qualify for tax credits or tax rebates to help offset the cost of your health insurance
The website allows you to search, compare and obtain health insurance on a single website
The website only offers health insurance plans that meet a set of federal quality standards
The website provides you someone to talk to regarding your health insurance plan choices
The website tells you how much your health insurance would cost you without having you register or follow up in any way
The website allows you to compare your existing health insurance plan to others available in your area
The website provides access to health insurance plans similar to those available to Federal employees
Your member of Congress was required to get their health insurance from the new Health Insurance website
SCALE:
Very helpful
Somewhat helpful
Not very helpful
Not helpful at all
DK
REF
PG5. Which of the following statements best describes how you feel about <TOPIC OR INITIATIVE EX: HEALTH INSURANCE, PREVENTIVE CARE, MEDICARE>? It:
Is a necessity, something I would never give up
Is very important, but not a necessity
Is good to have, but not all that important
Has little or no value to me
DK
REF
PG6. In general, how favorable or unfavorable is your opinion of <TOPIC OR INITIATIVE EX: HEALTH CARE REFORM, THE MEDICARE PROGRAM, HEALTH INSRUANCE EXCHANGES>?
Very favorable
Somewhat favorable
Somewhat unfavorable
Very unfavorable
DK
REF
PG7. How confident are you that you can <PERFORM ACTIVITY EX: IDENTIFY WHEN IT IS NECESSARY FOR YOU TO GET MEDICAL CARE, FIND INFORMATION ON A WEBSITE, REVIEW AND COMPARE HEALTH PLANS>?
Very confident
Somewhat confident
Not very confident
Not at all confident
DK
REF
PG8. How <CHARACTERISTIC EX: TRUSTWORTHY, USEFUL, COMPLETE> is the information you found on/at/in <LOCATION EX: WEBSITE, HANDBOOK, HOTLINE>?
Very <CHARACTERISTIC>
Somewhat <CHARACTERISTIC>
Not very <CHARACTERISTIC>
Not at all <CHARACTERISTIC>
DK
REF
PG9. Please indicate how much you agree or disagree with the following <ATTRIBUTES OF MATERIALS>
Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree
DK
REF
PG10. What is your opinion of <TERM, TOPIC, INITIATIVE, BENEFIT, BARRIER>? Do you find it to be
<SCALE RESPONSES INCLUDING:>
Very positive/useful/informative/favorable
Somewhat positive/useful/informative/favorable
Somewhat negative/unfavorable Not very useful/informative
Very negative/unfavorable Not at all useful/informative
DK
REF
PG11. (Present multiple)<TERM, TOPIC, INITIATIVE, BENEFIT, BARRIER>: Which term do you find to be most/least <CHARACTERISTIC EX: MOTIVATING, POSITIVE, IMPORTANT>?
PG12. Compared to <COMPARISON GROUP EX: LARGE COMPANIES, PARENTS>, how would you rate the health insurance options available to <UNIT EX: YOU, YOUR EMPLOYEES>. Would you say that your options are:
Better
About the same
Worse
DK
REF
Screening Questions
SG1. Have you or any member of your household or immediate family ever worked for:
A market research company
An advertising agency or public relations firm
The media (TV/radio/newspapers/magazines)
A healthcare profession (as a doctor, nurse, other healthcare professional, in a pharmacy, for a pharmaceutical company, etc.)
A health insurance provider
A managed care organization or any healthcare provider
A medical practice
<SPECIFIC ORGANIZATION THAT MIGHT INTORODUCE A BIAS DUE TO RESEARCH TOPIC>
DK
REF
SG2. Have you (or anyone in your household) ever worked for the Social Security Administration or the Centers for Medicare & Medicaid Services (CMS), formerly known as the Health Care Financing Administration?
Yes
No
DK
REF
SG3. What is the primary language spoken in your household/What language do you usually speak when you are at home? (OPEN END)
SG4. <TIMEFRAME EX: DO YOU CURRENTLY, HAVE YOU EVER> help or assistance to <PERSON EX: SPOUSE, FAMILY MEMBER, FRIEND> with <HEALTH ISSUE EX: CHOOSING A HEALTH PLAN, CHOOSING A DOCTOR, MAKING MEDICAL APPOINTMENTS, UNDERSTANDING HEALTH INFORMATION>
Yes
No
DK
REF
SG5. What types of assistance do you/have you provided for <PERSON EX: SPOUSE, FAMILY MEMBER, FRIEND> <TYPES OF HELP PROVIDED, INCLUDING>:
Insurance decisions
Health care decisions
Spoken with a healthcare provider on behalf of or along with someone else
Financial and legal decisions
Paying bills
Transportation
Household chores or grocery shopping
Other (Specify)
None of these
SG6. What is your relationship to the person for whom you provide assistance?
Spouse
Child
Parent
Grandparent
Other family member
A friend
Employee
Other (Specify)
SG7. Do you receive any form of compensation for providing assistance to <PERSON EX: SPOUSE, FAMILY MEMBER, FRIEND>?
Yes
No
DK
REF
SG8. <TIMEFRAME EX: EVER, PAST 12 MONTHS> participated in a <SESSION EX: FOCUS GROUP,
SURVEY, INTERVIEW> in which you were asked your opinions regarding a product, service or advertising?
Yes
No
DK
REF
SG9. <TIMEFRAME EX: HOW OFTEN, HAVE YOU EVER> used <MATERIALS EX: HANDBOOK, WEBSITE, FACTSHEET>? (OPEN END)
SG10. Do you have any chronic health conditions that require ongoing care, such as arthritis, chronic pain, high blood pressure, or heart disease?
Yes
No
DK
REF
SG10A. What is the nature of your chronic health condition? (OPEN END)
SG11. Do you have major responsibility for providing care to someone with a disability or another person, like a parent, spouse, or friend?
Yes
No
DK
REF
SP1. What percent of your full-time working hours are typically spent in direct patient care activities, as opposed to academics, research, or administration?
Zero to 24% of your working time
25% to 49% of your working time
50% to 74% of your working time
75% or more of your working time
DK
SP2. Approximately what percent of your practice’s revenues would you say come from <PROGRAM EX: MEDICARE/CHIP/MEDICAID>?
Zero to 19%
20% to 39%
40% to 59%
60% to 79%
80% or more
DK
SP3. Does your practice currently accept new <PROGRAM EX: MEDICARE/CHIP/MEDICAID> patients?
Yes
No
DK
SBO1. Are you the person who makes health insurance decisions for your <UNIT EX: FAMILY, SELF, BUSINESS>?
Yes
No
DK
REF
SBO2. Including yourself, how many employees does your company have?
1
2-9
10-19
20-49
50-100
>100
SBO3. What industry does your company serve? (OPEN END) SBO4. How long have you been in business? (OPEN END)
Qualitative Item Bank
Awareness
Items listed in this section would be used during qualitative data collection, during focus groups and interviews. These data collection efforts may take place in person, via the telephone, or on the internet.
AW1. What, if anything, you heard of <CMS TOPIC, INITIATIVE, WEBSITE>?
AW1A. Where did you hear about <CMS TOPIC, INITIATIVE, WEBSITE>? AW1B. What did you hear that was positive?
AW1C. What did you hear that was negative? AW1D. What did you hear that was confusing?
AW1E. What did you hear that seemed most important?
AW2. Looking at this <ITEM EX: CREATIVE CONCEPT, WEBPAGE MOCKUP>, what are the first things you notice?
AW2A. What is it about <RESPONSE> that made you notice?
AW2B. What words or phrases stand out to you/got your attention? AW2C. Are there words or phrases that should be said differently?
AW3. What would be the best way to get information about <TOPIC> to you/people like you?
Behavior
B1. Please describe how you would/usually/typically <BEHAVIOR EX: LOOK FOR INFORMATION ABOUT HEALTH INSURANCE>.
B2. What are the reasons that you have/have not <BEHAVIOR EX: GONE TO THE DOCTOR, RECEIVED PREVENTIVE CARE>
Knowledge
K1. In your own words, please describe <CMS TOPIC, INITIATIVE, WEBSITE>/If you wanted to describe
<CMS TOPIC, INITIATIVE, WEBSITE> to someone else, what would you say?
K1A. What is positive/good about <CMS TOPIC, INITIATIVE, WEBSITE>? K1B. What is negative/bad about <CMS TOPIC, INITIATIVE, WEBSITE>? K1C. What is confusing about <CMS TOPIC, INITIATIVE, WEBSITE>?
K1D. What is important about <CMS TOPIC, INITIATIVE, WEBSITE>?
K2. When you think about <CMS TOPIC, INITIATIVE, WEBSITE>, what are the first things that come to mind?
K3. What do you think is the purpose/main idea of <CONCEPT, CMS TOPIC, INITIATIVE, WEBSITE>?
K3A. How well do you think the purpose/main idea comes across? K3B. What could make it clearer?
K3C. What do you think this <CONCEPT, CMS TOPIC, INITIATIVE, WEBSITE> wants to motivate people to do?
K3D. How easy or difficult was <MATERIAL> to understand?
Perceptions
PE1. How easy/difficult is the information/material to understand?
PE1A. What could make it easier for people to understand this information? PE1B. What was a particularly difficult concept?
PE2. What <VALUE JUDGEMENT EX: DO YOU LIKE/DISLIKE, THINK IS MOST IMPORTANT, DO YOU FIND HARD TO UNDERSTAND> about <ITEM, CMS TOPIC, INITIATIVE, WEBSITE>?
PE2A. What makes you feel that way about it?
PE2B. What exactly do you <VALUE EX: LIKE, FIND IMPORTANT>?
PE3. What kind of person do you think <CMS TOPIC, INITIATIVE, WEBSITE> is for?
PE3A. What makes it right for that kind of person? PE3B. What makes it not right for other kinds of people?
PE4. How well do you think <CMS TOPIC, INITIATIVE, WEBSITE> would meet <HOUSEHOLD UNIT EX: YOU, PERSON YOU PROVIDE CARE FOR, YOUR CHILD> needs?
PE6. In your opinion, does <ITEM EX: CREATIVE CONCEPT, WEBPAGE MOCKUP, PHOTOGRAPH> prompt you to <BEHAVIOR EX: REVIEW AND COMPARE HEALTH PLANS, USE WEBSITE>?
PE6A. What would make you more likely to <BEHAVIOR EX: REVIEW AND COMPARE HEALTH PLANS, USE WEBSITE>?
PE6B. What could be done to make <ITEM EX: CREATIVE CONCEPT, WEBPAGE MOCKUP, PHOTOGRAPH> more likely to get you to <BEHAVIOR EX: REVIEW AND COMPARE HEALTH PLANS, USE WEBSITE>?
PE7. What, if anything, do you think should be included in <ITEM EX: CREATIVE CONCEPT, WEBPAGE MOCKUP, MATERIAL> that is not there currently?
PE8. How <VALUE JUDGEMENT EX: IMPORTANT, PERSONALLY RELEVANT> is <TOPIC> to you?
PE8A. What makes it <VALUE JUDGEMENT>?
PE8B. What do you think <TOPIC> means/will mean to you personally?
PE9. What, if anything, did this <ITEM EX: CREATIVE CONCEPT, WEBPAGE MOCKUP, MATERIAL> include that you did not already know?
PE10. What kind of person do you think <CMS TOPIC, INITIATIVE, WEBSITE> is for/Who do you think does <ITEM EX: CREATIVE CONCEPT, WEBPAGE MOCKUP, MATERIAL> is trying to reach?
PE10A. What makes it right for that kind of person/people? PE10B. What makes it not right for other kinds of people? PE10C. Who do you think would benefit most from <TOPIC>?
PE11. How easy/difficult do you think it would be/is it/was it for you to <BEHAVIOR EX: UNDNERSTAND, TAKE ACTION>?
PE11A. What would make/makes/made it easy/difficult to do? PE11B. What would make it easier?
PE11C. How likely would you be to <BEHAVIOR>? PE11D. Have you ever <BEHAVIOR> in the past? PE11E. What are the barriers to <BEHAVIOR>?
PE11F. What would make <BEHAVIOR> easier?
PE12. What is your reaction to <CONCEPT, CMS TOPIC, INITIATIVE, WEBSITE>?
PE12A. What makes you react in that way? PE12B. What could improve your reaction?
PE13. How does <CONCEPT, CMS TOPIC, INITIATIVE, WEBSITE> make you feel?
PE13A. What about <CONCEPT, CMS TOPIC, INITIATIVE, WEBSITE> makes you feel that way? PE13B. What could be done to improve the way you feel about it?
PE14. When it comes to <ITEM, CONCEPT, CMS TOPIC, INITIATIVE, WEBSITE> what (if anything) do you agree/disagree with?
PE15. How believable is <ITEM, CONCEPT, CMS TOPIC, INITIATIVE, WEBSITE> to you?
PE15A. What makes it believable/unbelievable? PE15B. What would make it more believable?
PE16. How would it/does it make you feel to know that <ORGANIZATION or INSTITUTEION EX: GOVERNMENT, AMERICAN MEDICAL ASSOCIATION> is involved with <TOPIC>?
PE16A. How do you think the government/HHS/CMS should be involved?
PE16B. What do you think it would mean for the government/HHS/CMS to be involved? PE16C. How do you think the involvement of the government/HHS/CMS will affect <TOPIC>? PE16D. What advantages would there be to the government/HHS/CMS being involved?
PE16E. What disadvantages would there be to the government/HHS/CMS being involved? PE16F. Who should be involved?
Preferences
PR1. Which <ITEM EX: CREATIVE CONCEPT, WEBPAGE MOCKUP, PHOTOGRAPH> do you <FEELING EX: LIKE, PREFER, FIND MOST MOTIVATING>?
PE1A. What is it that makes you feel like that about it?
PE1B. What made you choose that <ITEM> over other items? PE1C. What did you like less about <UNCHOSEN ITEM>?
PR2. What do you like most/least about <CMS TOPIC, INITIATIVE, WEBSITE>?
PE2A. What makes you feel that way about it?
PR3. What other words can be used to describe <CMS TOPIC, INITIATIVE, WEBSITE>?
PR4. What is your impression of <ITEM EX: CREATIVE CONCEPT, WEBPAGE MOCKUP, PHOTOGRAPH>
PR4A. What gives you that impression?
PR5A. How could this be changed to improve your impression?
PR5. How does of <ITEM EX: CREATIVE CONCEPT, WEBPAGE MOCKUP, PHOTOGRAPH> make you feel?
PR5A. What is it that makes you feel that way?
PR6. What was most/least appealing about <ITEM EX: CONCEPT, CMS TOPIC, INITIATIVE, WEBSITE>?
PE13A. What made that appealing/unappealing? PE13B. What could make it more appealing?
PR7. Looking at these <ITEM EX: CREATIVE CONCEPT, WEBPAGE MOCKUP, PHOTOGRAPH>, which one
do you find most/least <FEELING EX: MOTIVATING, ATTENTION GRABBING>?
PR7A. What is it that makes it most/least <FEELING EX: MOTIVATING, ATTENTION GRABBING>? PR7B. What could make it more <FEELING EX: MOTIVATING, ATTENTION GRABBING>?
Usability
US1. Using this <ITEM EX: WEBSITE, HANDBOOK, NOTICE>, please try to <ACTION EX: FIND ANSWER TO QUESTION, FILL OUT FORM>.
US1A. Tell me what you are doing as you go through the process.
US1B. How easy/difficult was it to <ACTION EX: FIND ANSWER TO QUESTION, FILL OUT FORM>? US2B. Do you feel that you were successful in <ACTION EX: FIND ANSWER TO QUESTION, FILL OUT FORM>?
US2C. What was the easiest/most difficult part of <ACTION EX: FIND ANSWER TO QUESTION, FILL OUT FORM>?
US2D. What could have made that task easier?
US2E. How likely is it that you would use this <ITEM> to <TASK> if you had to do it just like you did now?
US2F. How (if at all) have you ever done <TASK> in the past?
US2G. Was <TASK> harder or easier to do with <ITEM> than how you did it before? US2H. What made <TASK> easier/harder today?
US2. How likely would you be to use this <ITEM> to <ACTION EX: FIND ANSWER TO QUESTION, FILL OUT FORM>?
Sources of Information
SOI1. Have you ever looked for information about <TOPIC>?
SOI1AHow have you gone about looking for/trying to get information about/getting answers to
<TOPIC/CHALLENGE>?
SOI1B. Where have you found the most useful information?
SOI1C. How often do you pick up information about <TOPIC> from <SOURCE>? SOI1D. How do you choose where to go for information about <TOPIC>?
SOI2. Have you ever used/how likely would you be to use <ITEM EX: WEBSITE, FACT SHEET, PERSON> to find out about <TOPIC>?
SOI2A. How useful was <ITEM>?
SOI2B. What could have made it more useful?
SOI2C. Were you able to find the information you needed?
SOI2D. How confident were you that the information you found was correct?
SOI3. What sources of information do you trust most/least for information about <TOPIC>?
SOI3A. What makes for a trusted source of information?
SOI3B. How trustworthy do you think <SOURCE> is for information about <TOPIC>? SOI3C. What organizations do you trust most?
SOI4. Is this the type of <ITEM> you would expect to come from the government/HHS/CMS?
SOI4A. What makes you feel that way?
SOI5. Where would you expect to see information about <TOPIC>?
SOI5A. Where would you like to be able to see/get information about <TOPIC>? SOI5B. In what format would you like to see/get information about <TOPIC>
General Questions
G1. Please tell me more about why you say <RESPONDENT’S REPSONSE>.
G2. Please share any suggestions you have for improving <CHARACTERISTIC EX: THE DESIGN, USABILITY, DESCRIPTION, CONTENT> of <ITEM EX: CREATIVE CONCEPT, WEBPAGE MOCKUP, PHOTOGRAPH>.
G3. What, if anything did you learn from <ITEM EX: CREATIVE CONCEPT, WEBPAGE MOCKUP, PHOTOGRAPH>?
G4. Where would you go to find/what would you enter into a search engine to find
<ITEM/INFORMATION>?
G5. What questions do you have about <TOPIC>?
G5A. Where would you go/what would you do to get answers?
Activities
ACT1. {Distribute written materials) Please read this information about <TOPIC> and circle the words or phrases that <CONSTRUCT EX: YOU LIKE, SEEM DOABLE, ARE MOTIVATING> and put a line through the words of phrases that <OPPOSITE CONSTRUCT>
ACT1A. (Going over what was circled/lined) What made you <CONSTRUCT> this word/phrase? ACT1B. What could make this word/phrase more <POSITIVE CONSTRUCT>?
ACT2. (Distribute worksheet with ratings scales) Please rate/rank the <ITEM> using <SCALE>.
ACT2A. Show of hands – who rated <ITEM> <SCALE SCORE/RANK ORDER>? ACT2B. Why did you rate <ITEM> in that way?
ACT2C. What would have made you rate/rank <ITEM> higher?
ACT3. (Distribute worksheet) <GENERATIVE TASK EX: WRITE DOWN YOUR THOUGHTS ABOUT TOPIC; WRITE WHAT YOU WOULD SAY TO YOUR DOCTOR ABOUT TOPIC>
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Social Marketing & Consumer Testing Item Bank, OMB No. CMS 10437 |
| Subject | OMB Clearance Package, OMB Number: CMS-10437, Social Marketing & Consumer Testing Research |
| Author | CMS, OC |
| File Modified | 0000-00-00 |
| File Created | 2024-09-06 |
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