Form 6 Attachment F: Quarterly New Tool Usage Survey

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Survey #6: New Tool Survey (Web Site Users)

Demographic Questions

1. What type of health care practitioner best describes you?

 Administrator/Clinical manager

 Care manager/Case manager

 Clinical nurse specialist

 Clinical psychologist

 Clinical social worker

 Dentist

 Diabetes educator/Diabetes management nurse

 Health care navigator/Patient navigator

 Medical assistant

 Certified nurse midwife

 Nurse

 Nurse practitioner

 Occupational therapist

 Patient health educator/Certified health education specialist (CHES)

 Pharmacist

 Physician assistant

 Physician

 Psychiatrist

 Quality improvement manager

 Registered dietitian

 Respiratory therapist

 Other (please specify)_____________

2. In what kind of setting do you practice most of the time?

 Academic institution

 Ambulatory/office-based care setting

 Behavioral health care setting

 Community health care setting

 Correctional facility

 Emergency department

 Federally qualified health center or other public health center

 Home care

 Hospice and/or palliative care setting

 Hospital based setting

 Long-term care facility

 Migrant worker health center

 Pharmacy setting

 Rehabilitation center

Public reporting burden for this collection of information is estimated to average 5 minutes per response, the estimated time required to complete the survey. 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: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

 Specialty clinic

 Substance use/abuse treatment center

 University health care/hospital setting

 Urgent care setting

 Veteran or military health care center/hospital

 Other (please specify) _______________

3. Have you participated in AHRQ’s Patient-Centered Outcomes Research in Shared Decisionmaking (PCOR in SDM) train-the-trainer workshop?

 Yes

 No

4. If you answered “No” to the above question, have you participated in a training session on PCOR in SDM that was offered by someone else (e.g., a work colleague) who participated in the AHRQ PCOR in SDM train-the-trainer workshop?

 Yes

 No

Use of New SMD Tools

5. How often have you used the following AHRQ SDM Toolbox tools/resources in the past 6 months?

	Daily or almost daily	At least once a week	Two to three times a month	About once a month	A couple of times in the past 6 months	Never
SDM toolbox Web page on the AHRQ Web site
SDM quick reference guide
Sample dialogue guide/Talking points
Cultural awareness checklist
Health literacy strategies summary
Implementation guide
Administrator brief about the benefits of implementing PCOR in SDM between providers and patients

6. How useful do you find the following AHRQ SDM Toolbox tools/resources?

	Very useful	Somewhat useful	Not very useful	Not at all useful	I did not use this tool/resource
SDM toolbox Web page on the AHRQ Web site
SDM quick reference guide
Sample dialogue guide/Talking points
Cultural awareness checklist
Health literacy strategies summary
Implementation guide
Administrator brief about the benefits of implementing PCOR in SDM between providers and patients

7. Have you shared any of the resources in the SMD Toolbox with a colleague?

 Yes

 No

8. Please describe any changes to existing tools or other new tools that you would like added to the SDM Toolbox to facilitate your implementation of PCOR in SDM with patients. ___________________________________________________________________________

9. Are there any additional comments you would like to share with us about the SDM Toolbox or specific tools? ____________________________________________________________________

ATTACHEMENT F: AHRQ EtE -- Survey 6 – Quarterly Survey about New Tools 5