Form 1 NLM GHR User Study Screening Survey Instrument

OMB NO: 0925-0648
EXPIRATION DATE: 03/31/2018

Public reporting burden for this collection of information is estimated to average10 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.

ICF is working on behalf of the U.S. National Library of Medicine to find out people's opinions of the Genetics Home Reference
website, This brief survey asks questions about you and your familiarity with this resource.. The results of the survey will be used
to select participants to be interviewed at greater length about their experience with Genetics Home Reference, Please be
mindful that completing this survey does not guarantee that you will be selected for an interview, nor does it obligate you to
participate if you are chosen. This survey will be open from mm/dd/yyyy to mm/dd/yyyy,
If you are selected for an interview, you will be contacted by e-mail and phone on or before rnrn/dd/yyyy. Interviews will be
conducted online and will be scheduled at your convenience. Each interview will last no longer than an hour. After participating in
an interview, you will receive a $25 Amazon.com Thank You card via e-mail. Your feedback will help us improve the Genetics
Horne Reference website for all of our users. If you have any questions, please email iva.stovneva@icf.com

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* 1. What is your age?

2. What is your gender?
__ Female
__ Male
__ Other
__Prefer not to answer

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Exit

GHR User Study Screening Survey

Thank you for participating in the survey. We are currently looking for people with different
characteristics for our interviews. We appreciate your interest.

Done

* 3. Do you have access to a computer with reliable internet access?
__Yes
__No

* 4. Do you have access to a phone?
__Yes
__No

* 5. Are you comfortable answering questions in English?
__Yes
__No

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* 6. What is the highest level of school you have completed or the highest degree you have received?
__ Less than high school degree
__High school degree or equivalent (e.g., GED)
__Some college but no degree
__Associate degree
__Bachelor's degree
__Graduate degree
__Prefer not to answer

* 7. How often do you visit the Genetics Home Reference website?
__ First time
__ Daily
__ Several times a week
__ About once a week
__ Several times a month
__ Several times a month
__ About once a month
__ Every few months
_ Other (please specify)

* 8. Which of the following best describes your role in visiting Genetics Home Reference today?
__Student
__Person with a health condition
__Family member or friend of person with a health condition
__I'm just curious
__ScientlstJResearcher
__Physician
__Other Healthcare Provider (e.g., nurse, physician assistant, pharmacist)
__ Genetic counselor
__Educator
__Librarian or other information professional
__ Journalist or other science writer
__Other (please specify)

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This information will be used only to contact you if you are selected to participate in an online interview. Your information will not
be shared with anyone else, and it will be deleted once all interviews are complete.

* 9. Contact

Information

First Name
Email Address
Phone Number

* 10. Please select the time slots in which you are available to be interviewed (in Eastern lime). You may select more than
one slot. We will email and call you to confirm your actual interview time.
s:ooam 9:ooam
1o:ooam 11:ooam - 12:00pm - 1:oopm - 2:oopm - 3:oopm - 4:0opm - 5:00pm 9:00am -10:00am -11:00am 12:00pm
1:00pm
2:oopm
3:00pm
4:00pm
5:00pm
6:00pm

EST

EST

EST

EST

EST

Monday, Month Date
Tuesday, Month Date
Wednesday, Month Date
Thursday, Month Date
Friday, Month Date

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EST

EST

EST

EST

EST

Thank you for completing this survey. The results of the survey will be used to select participants to be interviewed at greater
length about the Genetics Home Reference website. Please be mindful that completing this survey does not guarantee that you
will be selected for an interview, nor does it obligate you to participate if you are chosen. If you are selected, you will be
contacted by email and phone on or before mm/dd/yyyy.
If you have any questions, please email iva.stoyneva@icf.com

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