Health Planner End User Survey_2012 04 17

OMB Control Number: 0925-0648
Expiration Date: 01/2015

Health Planner User Survey

Thank you for giving us your feedback on the health planner you received. Your responses will help us improve the health planner in the future.

Please answer the following questions, and remember to provide your name and mailing address on the final page. When completed, mail the survey back to us in the stamped envelope included with this survey. Please fill out either the English or Spanish version of the survey but not both.

If you would like to complete the survey online INSTEAD of mailing it back to us, please go to the following website: http://www.surveymonkey.com/s/HealthPlanner.

Burden Disclosure Statement

Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0648).  Do not return the completed form to this address.

1. How did you get the health planner? (circle one)

1. Given to me by an outreach worker (Community Health Representative/promotor/other)

2. Picked it up at a health fair or other location

3. Received it in the mail

4. Other—Please explain:

2. Have you had the chance to use the health planner?

1. Yes

If yes, please describe how you used it.

2. No

If no, is there a reason why you did not use it yet? Do you plan to?

3. Overall, do you like the health planner?

1. Yes

2. No

4. Is the health planner easy to read?

1. Yes

2. No

5. Do you like the colors used in the health planner?

1. Yes

2. No

6. Are the photographs in the planner appropriate?

1. Yes

2. No

7. Have you (or would you) use the reminder stickers in the health planner?

1. Yes

2. No

8. Are the quotes in the health planner believable?

1. Yes

2. No

9. Are the scientific facts in the health planner useful?

1. Yes

2. No

10. Is it (or would it be) easy to write notes in the health planner?

1. Yes

2. No

11. Have you done anything differently as a result of the information in the health planner?

1. Yes

If yes, please describe what you did differently.

2. No

12. Do you plan do anything differently as a result of the information in the health planner?

1. Yes

If yes, please describe what you are planning to do differently (do not include any changes you already made and described in Question 11).

2. No

13. Did you call the toll-free number or go to the NIAMS website for more information?

1. Yes.

If yes, please describe the type of information you were looking for.

2. No

14. Did you share information from the health planner with family or friends?

1. Yes

2. No

15. What topics in the health planner are most important to you?

16. What do you like most about the health planner?

17. What do you like least about the health planner?

18. How do you think we could improve the health planner in the future?

19. Who do you think created the health planner?

20. Have you heard about the National Institutes of Health (NIH) before?  

1. Yes

2. No

21. Have you heard about the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) before?

1. Yes

2. No

22. Have you or would you ever contact the NIH or NIAMS?

1. Yes

If yes, please specify your reason for contacting either NIH or NIAMS.

2. No

Go to Question 24.

23. How would you most likely contact the NIH or NIAMS:

    1. Email

2. Toll-free Telephone Call

3. Regular Mail

4. NIAMS or NIH website

24. Additional comments:

THANK YOU!

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