Form 1 Web-based Survey

Form Approved

OMB No. 0935-0179

Exp. Date 10/31/2017

Questions for Patient Key Informants

Number: 1-2 per Topic Refinement or Tech Brief, approximately 30-40/year

Method: electronic survey sent at end of report

1. Using any number from 0 to 10 where 0 is the worst possible and 10 is the best possible, what number would you use to rate your experience participating in the AHRQ systematic review process?

2. Do you think the final report will be useful to patients like you? (Yes, definitely; Yes, somewhat; No)

   1. Explain: _______________________

3. Do you feel like your comments were used in the final report? (Yes, definitely; Yes, somewhat; No)

   1. Explain: __________________________

4. Would you recommend other patients participate as key informants for future AHRQ systematic reviews? (Yes/No)

   1. Explain:______________________

5. What could have improved your experience participating as a key informant? _______________________________________________________

Public reporting burden for this collection of information is estimated to average 15 minutes per response, the estimated time required to complete the survey. An agency many 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 (0935-0179) AHRQ, 5600 Fishers Lane, Mail Stop 07W41A, Rockville, MD 20857.