ATTACHMENT 5
Demographic Survey
Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX
Demographic Survey
1. Race
1. American Indian or Alaskan Native
2. Asian
3. Black or African American
4. Hispanic
5. Native Hawaiian or Other Pacific Islander
6. White
7. Prefer not to answer
2. Yearly household income
1. <$20,000
2. $20,000-$40,000
3. $40,000-$60,000
4. $60,000-$80,000
5. >$80,000
6. Prefer not to answer
3. Medical condition treated for in the Pediatric Respiratory Medicine Clinic (circle all that apply)
1. Asthma
2. BPD
3. CF
4. Sleep Disorder
5. Other:_____________________________________
4. Do you have access to the internet?
1. Yes
2. No
5. If yes, where do you have access (circle all that apply)?
1. Home
2. Personal digital assistant (ex. Blackberry)
3. School
4. Work
5. Other:________________________________
Public reporting burden for this collection of information is estimated to average 10 minutes per response, the estimated time required to complete the survey. 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, 540 Gaither Road, Room # 5036, Rockville, MD 20850
6. How often do you currently call the Pediatric Respiratory Medicine Office (nurse or doctor)?
1. Never
2. Less than once a month
3. 1-3 times a month
3. 1-2 times a week
4. Greater than twice a week
7. Who is the one calling the Pediatric Respiratory Medicine Office (nurse or doctor)?
1. Both parent/guardian and child
2. Child
3. Parent/Guardian
8. Place the following list in order from the most common reason you call the Pediatric Respiratory Medicine Office (nurse or doctor) to the least common reason you call.
1. Appointment issue _______
2. Medication Refill _______
3. Not feeling well _______
4. Prior authorization/insurance issue _______
5. To find out test results _______
6. To give an update on how you are feeling _______
9. How would you prefer to contact the Pediatric Respiratory Medicine Office (nurse or doctor) for the following reasons:
9.1 Medication Refill
1. E-mail
2. In person
3. Telephone
4. Other ______________
9.2 Prior authorization/insurance issue
1. E-mail
2. In person
3. Telephone
4. Other ______________
9.3 Not feeling well
1. E-mail
2. In person
3. Telephone
4. Other ______________
9.4 To give an update on how you are feeling
1. E-mail
2. In person
3. Telephone
4. Other ______________
9.5 To find out test results
1. E-mail
2. In person
3. Telephone
4. Other ______________
9.6 Appointment issue
1. E-mail
2. In person
3. Telephone
4. Other ______________
By completing this survey, I am consenting to be a part of the study that was explained to me and was described in the Secure Health Messaging for Pediatric Patients information sheet.
| File Type | application/msword |
| File Title | ATTACHMENT 5 |
| Author | DHHS |
| Last Modified By | DHHS |
| File Modified | 2008-02-27 |
| File Created | 2008-02-21 |