APPENDIX A
SURVEY INSTRUMENT
OMB No 0925-0648
Exp. Date 01/01/2015
NCCAM Clearinghouse Telephone Survey
Public reporting burden for this collection of information is estimated to average 5 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.
May I ask you a few questions to help us evaluate our program and see whom we are serving?
This NCCAM-sponsored survey should take approximately 5 minutes. Your responses will be protected to the extent allowed by law. Participation is voluntary; you may decline to answer any or all of the questions.
Have you taken the survey before?
Do you want to take the survey based on today’s call?
NOTE: Responses in all
capital letters are NOT read aloud to the respondent.
1. Have you contacted us before?
YES
NO
DON'T
KNOW/DON'T REMEMBER
DID NOT REPLY
2. How did you first find the NCCAM Clearinghouse telephone number?
NCCAM WEBSITE
FROM
ANOTHER WEBSITE
WRITTEN CORRESPONDENCE FROM NCCAM
CLEARINGHOUSE
REFERRED BY FRIEND/FAMILY
REFERRED BY
HEALTH CARE PROVIDER
REFERRED BY CO-WORKER OR COLLEAGUE
MEDIA(MAGAZINE, NEWSPAPER, TELEVISION, RADIO)
DON'T
KNOW/DON'T REMEMBER
OTHER (SPECIFY)
DID NOT REPLY
3. Please tell me if you strongly agree, agree, disagree, or strongly disagree with the following statements about the NCCAM Clearinghouse:
STRONGLY AGREE
AGREE
DISAGREE
STRONGLY
DISAGREE
DID NOT REPLY
The information provided to
me was appropriate to the question I asked.
The
way information was communicated was clear and easy to understand.
Overall, I was satisfied with the information I
received today.
4. Which of the
following best describes you? (Select one.)
Patient
Family or friend
of patient
Interested public
CAM practitioner
Other
health care provider
Researcher or grant applicant
Journalist/media professional
Student
Other
(specify)
DID NOT REPLY
5. What is your age?
20 or under
21-30
31-40
41-50
51-60
61-70
71 or over
DID NOT REPLY
6. What is your gender?
Female
Male
DID
NOT REPLY
7. What is the highest level
of education you have completed?
[Only ask patients/spouse,
relative, friend/general public]
High school graduate
Some college
College graduate
Post-graduate
DID NOT ASK
DID NOT
REPLY
8. Race and Ethnicity (Click
here for definitions.)
Ethnicity:
Hispanic or Latino
Not
Hispanic or Latino
I DO NOT WISH TO PROVIDE THIS INFORMATION
Race: (Select all that apply.)
American Indian or
Alaska Native
Asian
Black or African American
Native
Hawaiian or Other Pacific Islander
White
I DO NOT WISH TO
PROVIDE THIS INFORMATION
9. What country are you calling from?
UNITED STATES
ASK
FOR HOME ZIP CODE (United States only)
SPECIFY COUNTRY
That concludes our survey. Thank you for participating. Please call us again if you have other questions. Thank you for calling the NCCAM Clearinghouse.
| File Type | application/msword |
| File Title | NEWSLETTER SURVEY |
| Author | Alyssa Cotler |
| Last Modified By | Perryman |
| File Modified | 2013-04-01 |
| File Created | 2013-04-01 |