2 Web Screener Survey

Form Approved

OMB No. xxxx-xxxx

Exp. Date xx/xx/22

 

Web Screener Survey

Toaster Text (Toaster message on website)

Help us improve our website with this 3-minute survey.

Buttons:

• “I’ll Help” - this will open the survey in a new window

• “No Thanks” - this will close the toaster

Welcome Message

Thank you for helping with our short survey. We are interested in hearing your feedback on the site!

Questions

• What is your profession?

• Administrator or Manager of Hospital, Health Plan, or Medical Group

• Allied Health Professional (OT, PT, Social Worker, etc.)

• Federal/State Policymaker

• Nurse/Nurse Practitioner

• Patient Safety Educator

• Patient safety Officer

• Patient Safety Researcher

• Patient

• Quality Improvement Professional

• Risk management Professional

• Physician/ Physician Assistant

• Which of the following best represents your primary affiliation?

• Academic institution, university, or medical school

• Hospital or health care system

• Ambulatory care

• Federal government agency

• Insurance company

• Quality/patient safety organization (excluding federal, state, or local government)

• State or local government agency

• Other (write in) _________________

• How many years of experience do you have in the Patient Safety field?

• 1-4

• 5-14

• 15-24

• 25+

• Approximately how often do you visit the AHRQ PSNet site?

• First time

• Daily

• Weekly

• Monthly

• Less than once a month

• What brings you to PSNet today?

  • Text Box

• Would you be willing to help us further with our research study to make the website even better?

• Yes

• No

• If Yes
  Please provide your contact information.

  • Name (text box)

  • Email (text box)

Public reporting burden for this collection of information is estimated to average 3 to complete the survey and, if volunteered and selected, 60 minutes for a follow-up conversation. All information collected will be kept confidential (42 U.S.C. 299c-3(c)) and included as part of the assessment of participant experience and implementation of best practices. An individual’s name will not be shared and responses will not be attributed to a specific individual. 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 (0935-0179) AHRQ, 5600 Fishers Lane, Mail Stop Number 07W41A, Rockville MD 20857

Thank you Text

Thank you again for your participation. Your feedback is incredibly useful, and we appreciate all your time and effort. If you are eligible for a follow-up interview, we will contact you by email.

You may now close this window or navigate to another web page.