Supporting Material 2

Gallup^® is a trademark of The Gallup Organization. All other trademarks are the property of their respective owners. Copyright © 2006 The Gallup Organization, Princeton, NJ. All rights reserved.

WEB

Application ID#:

URL: https://gx.gallup.com/htrecruit.gx

Project Registration #146640
U.S. DEPT. OF HEALTH AND HUMAN SERVICES	N TRANSLATIONS
City Center: Washington, DC
Heart Truth Recruit/Screener
Wells/Dean	X SURVEY DESIGN: Tara McGhee
Edward Purvis, Programmer
November, 2006	n=

We are contacting you because you accessed the Women’s Heart Truth materials on the National Women’s Health Information Center Web site. When you downloaded the materials it was stated that you would be contacted for a follow up survey.

Now, we would like you to answer a few questions about how you have used the materials that you downloaded.

Please enter your Access Code below, and click the "Begin Survey" button to continue.

<Begin Survey>

(PROGRAMMER NOTE: If incorrect Access Code, display the following error message:)

The Access Code you have entered is invalid. Please carefully re-enter your Access Code.

(PROGRAMMER NOTE: If no Access Code is entered, display the following error message:)

You must enter an Access Code to continue.

ACCESS CODE USAGE:

Allow one complete per Access Code

Allow multiple completes per Access Code

Allow both of the above (with instructions if Access Codes are Business Unit Level, Associate Level, or an Access Code Range)

(PROGRAMMER NOTE: Display the following at the bottom of each screen:)

If you need assistance completing this survey, please contact Gallup Client Support by sending an e-mail to galluppoll@gallup.com or by calling 1-888-297-8999 from 8:00 a.m. to 8:00 p.m. Eastern Time, Monday through Thursday, or 8:00 a.m. to 6:00 p.m. Eastern Time on Fridays.

Do not print, store, or copy this page.

Copyright © 2006 The Gallup Organization, Princeton, NJ. All rights reserved. Privacy Policy

1. Do you recall having downloaded The Heart Truth professional education materials?

1 Yes

2 No

3 Don't know

(If code 1 in #1, Continue;

Otherwise, Skip to Read #4 after #9)

2. Which of The Heart Truth materials have you downloaded from the National Women’s Health Information Center Web site? Did you download (rotate A-D)?

A. Lecture materials and PowerPoint slides

1 Yes

2 No

3 Don't know

B. Problem-based learning cases

1 Yes

2 No

3 Don't know

C. Standardized patient case

1 Yes

2 No

3 Don't know

D. Additional reference materials (such as Heart Truth Lecture References or Heart Diagrams)

1 Yes

2 No

3 Don't know

(If code 1 in #2 A, B, C, or D, Continue;

Otherwise, Skip to Read #4 after #9)

3. Why did you download the materials? (Rotate A-D)

A. Did you download materials for your own use?

1 Yes

2 No

3 Don't know

3. (Continued:)

B. Did you download materials for presentation to professionals or professional students?

1 Yes

2 No

3 Don't know

C. Did you download materials on behalf of someone else?

1 Yes

2 No

3 Don't know

D. Did you downloaded materials for some other reason?

1 Yes

2 No

3 Don't know

(If code 1 in #3-D, Continue;

Otherwise, Skip to Note before #4)

3a. For what other reason? (Fill in response) (Allow 200 characters)

(If code 1 in #3-B, Continue,

If code 1 in #3-C, Skip to #8;

If code 1 in #3-A, Skip to Read #6 after #9;

Otherwise, Skip to Read #4 after #9)

4. Have the materials been presented or are they going to be presented in the future?

1 The materials have been presented

2 The materials will be presented in the future

3 The materials have both been presented and will be presented again

4 Don't know

(If code 1 in #4, Continue;

If code 3 in #4, Skip to #7;

If code 2 in #4, Skip to #4b;

Otherwise, Skip to Read #4 after #9)

4a. On what date were the materials presented? (Fill in response) (Allow 8 digits)

(PROGRAMMER NOTE: Format: Month/Day/Year)

(XX/XX/XXXX)

(Error Message:)

Please enter numbers only.

(All in #4a, Skip to #5)

4b. On what date will the materials be presented? (Fill in response) (Allow 8 characters)

01 Don't know exact date yet (PROGRAMMER NOTE: Make this a check box)

(PROGRAMMER NOTE: Format: Month/Day/Year)

(XX/XX/XXXX)

(Error Message:)

Please enter numbers only.

(All in #4b, Skip to Text before #6)

5. We need to evaluate how professionals or professional students who were presented The Heart Truth materials have incorporated them into their practice. We are asking for your cooperation. To keep everything confidential, we would like for you to send an e-mail out (we will forward the e-mail to you at the appropriate time) to the professionals who attended your presentation a few months after the presentation. The e-mail will have a link to a short online questionnaire.

Would you be willing to cooperate with The Gallup Organization and forward the Gallup e-mail with the survey information to these professional or professional students to whom you presented The Heart Truth materials?

1 Yes

2 No

3 Contact me, I have questions

(All in #5, Skip to #9)

We want to evaluate if professionals or professional students who will be presented the The Heart Truth materials incorporate them into their practice. We are asking for you to compile a list of e-mail addresses of persons attending your presentation. We will then send you an e-mail that we will ask you to forward to those who attend your presentation (for confidentiality reasons, we ask you to send that e-mail). The e-mail will have a link to a short online questionnaire for those who saw the presentation.

6. Would you be willing to cooperate with The Gallup Organization and forward survey information to these professionals or professional students to whom you will be presenting The Heart Truth materials?

1 Yes

2 No

3 Contact me, I have questions

(All in #6, Skip to #9)

7. We need to evaluate how professionals or professional students who were presented The Heart Truth materials have incorporated them into their practice. We are asking for your cooperation. To keep everything confidential, we would like for you to send an e-mail out (we will forward the e-mail to you at the appropriate time) to the professionals who attended your presentation a few months after the presentation. The e-mail will have a link to a short online questionnaire.

Would you be willing to cooperate with The Gallup Organization and forward the Gallup e-mail with the survey information to these professional or professional students to whom you presented The Heart Truth materials?

1 Yes

2 No

3 Contact me, I have questions

In addition, because you will be presenting the materials again in the future, we would also like to ask for you to compile a list of e-mail addresses of persons attending the upcoming presentation. We will then forward another e-mail to you at the appropriate time. To keep names confidential, we would like for you to forward that e-mail to the professionals who will attend your presentation a few months after the presentation. The e-mail will have a link to a short online questionnaire.

(All in Read, Skip to #9)

8. Can you forward the e-mail address of the person who presented or will present The Heart Truth materials? Gallup assures the strictest confidentiality with this information. We will share this information with no one and will only contact this individual in reference to The Heart Truth presentation.

1 Yes

2 No

3 Don't know e-mail address

(If code 1 in #8, Continue;

Otherwise, Skip to Read #4 after #9)

E-MAIL ADDRESS: (Fill in response)

(Error Message:)

That is an invalid e-mail address. Please re-enter.

(All in E-MAIL ADDRESS, Skip to Read #4 after #9)

9. Which of the following best describes your profession?

01 Physician

02 Nurse, Nurse Midwife, Nurse Practitioner

03 Physician’s Assistant

04 Other (Fill in response) (Allow 100 characters)

(If code 1 in #4, Continue;

If code 2 in #4 AND valid date given in #4b,

Skip to Read #2;

If code 2 in #4 AND code 01 in #4b,

Skip to Read #3;

If code 3 in #4, Skip to Read #5;

Otherwise, Skip to Read #4)

(READ #1:) THANK YOU FOR YOUR PARTICIPATION!!! We will be forwarding the e-mail with the questionnaire link to you shortly.

(All in Read #1, Skip to Text before Submit Screen)

(READ #2:) THANK YOU FOR YOUR PARTICIPATION!!! Approximately two months after your presentation date, we will be forwarding the e-mail with the questionnaire link to you.

(All in Read #2, Skip to Text before Submit Screen)

(READ #3:) THANK YOU FOR YOUR PARTICIPATION!!! We will be contacting you in about one month to see if you have either completed or set a date for the presentation of The Heart Truth materials.

(All in READ #3, Skip to Text before Submit Screen)

(READ #4:) Thank you for your time.

(All in READ #4, Skip to Text before Submit Screen)

(READ #5:) THANK YOU FOR YOUR PARTICIPATION!!! We will be forwarding the e-mail with the questionnaire link to you shortly. Approximately two months after your next presentation date, we will be forwarding another e-mail with another questionnaire link to you. (Only the Access Code will differ.)

(All in READ #5, Skip to Text before Submit Screen)

(READ #6:) THANK YOU FOR YOUR PARTICIPATION!!! We would like your participation in our survey and will be sending you a link to the survey shortly.

We are required by law to inform you that we cannot conduct a survey unless it has a valid control number from the Office of Management and Budget. The OMB control number for this survey is XXXX-XXXX, which expires XX,2007.

(PROGRAMMER NOTE: Right above the "Submit Survey" button, display:)

Please submit your survey to Gallup by clicking the "Submit Survey" button below. Once you close your browser, you will no longer be able to view the survey or change your responses.

<Submit Survey>

Thank you for your cooperation.

You may now close your browser or go to another Web site.

jlw\USHHS_Heart_Truth_Evaluation\Questionnaires\WEB\2006\

US DHHS Heart Truth Screener WEB 0611

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US Department of Health & Human Services-Heart Truth Recruit/Screener 02/06/21