1 Patient and Caregiver Survey

Form Approved

OMB No. 0935-XXXX

Exp. Date XX/XX/20XX

Patient and Caregiver Survey

Public reporting burden for this collection of information is estimated to average XX 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, 5600 Fishers Lane, # 07W41A, Rockville, MD 20857.

Domain (group)	Question	Format
Demographic Questions	What is your age?	Number
	How do you currently describe yourself? (Mark all that apply)	List: - Female - Male - Transgender - I use a different term (free text)
	What is your race? (One or more categories may be selected)1	List: - American Indian or Alaska Native  - Asian  - Native Hawaiian or other Pacific Islander  - Black or African American  - White
	Are you Hispanic or Latino/Latina?	Yes/No
	What is the highest level of school that you have completed?	List: - 8th grade or less. - Some high school, but did not graduate. - High school graduate or GED. - Some college or 2-year degree. - 4-year college graduate. - More than 4-year college degree.
	What is your zip code?	Open Ended (format)
	How comfortable are you with technology?	Likert
Section Questions (repeated for 7 distinct sections: Concerns, Medications, Activities, Tests, Vitals, Immunizations, and Care Team)	Does the information displayed in the ________ section appear complete?	Yes/No
	(If no) Please list any information that should be displayed in the ________ section but is not:	Open Ended
	Is there any information displayed in the ________ section that should not be there (such as inaccurate information or information that is in the wrong place)?	Yes/No
	(If yes) Please list any information you see displayed in the ________ section that should not be there:	Open Ended
	I found the information displayed in the ________ section helpful.	1-5 Likert Scale
	Which information is or is not helpful?	Open Ended
	How could we make this section more helpful to you?	Open Ended
Functionality	I feel the various parts of this application work together well.	1-5 Likert Scale
	There are areas of inconsistency in the application.	1-5 Likert Scale
	[If 3, 4, or 5, describe what is inconsistent]	Open ended
	Did the application and individual pages load in a timely manner?	Yes/No
	Did you receive any error messages?	Yes/No
Usefulness	I think I would use the My Care Planner application frequently.	1-5 Likert Scale
	I found the application cumbersome/awkward to use.	1-5 Likert Scale
	I think myCarePlanner could improve communication among my care team.	1-5 Likert Scale
	Using myCarePlanner makes it more likely that my care team can help me get care that aligns with my goals.	1-5 Likert Scale
	I am comfortable with my ability to use myCarePlanner.	1-5 Likert Scale
	I find myCarePlanner easy to use.	1-5 Likert Scale
	I can always remember how to log on to and use myCarePlanner.	1-5 Likert Scale
External Health System EHRs	Have you logged onto multiple patient portals?	Yes/No
	(If yes) Does the information match what you expected? Is anything missing?	Open ended
	It was easy to find all of the places where I receive care.	1-5 Likert Scale
	If no, explain:	Open ended
	I found it helpful to be able to view information from all the places where I receive care at the same time, in one place.	1-5 Likert Scale
Writing Data from App	I opened the questionnaire section.	Yes/No
	(If yes) I attempted to complete a questionnaire.	Yes/No
	(If yes) I was able to successfully complete a questionnaire.	Yes/No
	I think the questionnaire feature will help me work with my care team to plan care.	1-5 Likert Scale
	I opened the goals section.	Yes/No
	(If yes) I attempted to write a goal.	Yes/No
	(If yes) I was able to successfully write a goal.	Yes/No
	I think the ability to write goals would help my healthcare team work together to develop a shared care plan that will work better for me.	1-5 Likert Scale
Patient/ Caregiver Dynamics	A caregiver is part of my care team.	Yes/No
	(If yes) I think my caregiver would benefit from access to the application.	1-5 Likert Scale
	I am a caregiver for another person.	Yes/No
	(If yes) Having access to MyCarePlanner for the person I care for would make my job as a caregiver easier.	1-5 Likert Scale
	(If no) Did someone help you complete this survey?	Yes/No
	(If yes) How did that person help you?	List: - Read the questions to me - Wrote down the answers I gave - Answered the questions for me - Translated the questions into my language - Helped in some other way