Evaluation of ARRA Comparative Effectiveness Research Dissemination Contract Efforts

Form Approved

OMB No. 0935-0191

Exp. Date 3/31/2015

AHRQ CER Dissemination Evaluation—Consumer Survey Screener

S1. Hello, my name is [INTERVIEWER NAME] and I am calling from IMPAQ International on behalf of the Agency for Healthcare Research and Quality. May I speak to [RESPONDENT NAME]?

SAMPLE MEMBER AVAILABLE, GO TO S2.

SAMPLE MEMBER NOT AVAILABLE, GOT TO TAB THAT APPLIES

Non response

Appointment

Other

No Answer

Answer Machine

Disconnected

Busy

Help

Phone Collection

Phone Collection

S2. We are conducting a short survey for the Agency for Healthcare Research and Quality. You may have recently received a letter explaining the study to you. The purpose of the survey is to learn about your awareness of research that may help you make decisions about your health care. The survey takes about 15-20 minutes to complete. Are you willing to participate?

OK TO CONTINUE....................... 1 → GO TO S3

NOT A GOOD TIME ...................... 0 → GO TO APPOINTEMNT TAB

REFUSED............................................... 7 → GO TO HELP TAB, NON RESPONSE TAB, or CONTINUE TO SURVEY IF THE REPOSDENT EVENTUALLY AGREES

R HESTITATES TO DO SURVEY....................9→ GO TO HELP TAB, NON RESPONSE TAB, or CONTINUE TO SURVEY IF THE REPOSDENT EVENTUALLY AGREES

R HAS QUESTION ABOUT THE STUDY......... 6→ GO TO HELP TAB, NON RESPONSE TAB, or CONTINUE TO SURVEY IF THE REPOSDENT EVENTUALLY AGREES

S3. Thank you. Before we begin the survey, I need to ask a few questions to determine your eligibility.

OK TO CONTINUE.......................................1→ GO TO S4

NOT A GOOD TIME FOR SM ..................... 0→ GO TO APPOINTMENT TAB

REFUSED................................................... 7→ GO TO HELP TAB, NON RESPONSE TAB, or CONTINUE TO SURVEY IF THE REPOSDENT EVENTUALLY AGREES

R HESTITATES TO DO SURVEY....................9→ GO TO HELP TAB, NON RESPONSE TAB, or CONTINUE TO SURVEY IF THE REPOSDENT EVENTUALLY AGREES

R HAS QUESTION ABOUT THE STUDY......... 6→ GO TO HELP TAB, NON RESPONSE TAB, or CONTINUE TO SURVEY IF THE REPOSDENT EVENTUALLY AGREES

S4. Do you consider yourself to be fluent in English?

YES....................... 01 → GO TO S5

NO........................ 02 → Unfortunately you are not eligible for the survey. Thank you for your time. TERMINATE.

S5. Do you or does someone in your household work for the Agency for Healthcare Research and Quality?

YES....................... 01 → Unfortunately you are not eligible for the survey. Thank you for your time. TERMINATE.

NO........................ 02 → GO TO S6

S6. Are you a health care provider (i.e. physician, nurse, allied health worker) or work for a medical device or prescription drug company?

YES....................... 01 → Unfortunately you are not eligible for the survey. Thank you for your time. TERMINATE.

NO........................ 02 → GO TO S7

INTERVIEWER, IF NEEDED: Examples of medical devices include pacemaker, hospital or surgical instruments, thermometers, and blood sugar meters.

S7. Have you visited a doctor or other health care professional in the past 12 months?

PROBE IF NECESSARY: This could include a doctor, nurse, physician assistant or other type of health care professional.

YES....................... 01 → GO TO S8

NO........................ 02 → Unfortunately you are not eligible for the survey. Thank you for your time. TERMINATE.

S8. Before we begin the survey, we want to emphasize that your participation is completely voluntary. The Agency for Healthcare Research and Quality, or "Ark" for short, has obtained approval to conduct the survey from the federal government's Office of Management and Budget. Anything you say will be kept confidential and your name will not be used in any way. Your answers will not be shared with anyone outside of Ark in any manner that would enable someone to identify you. You may refuse to answer any question we ask, and you may discontinue participation at any time. However, we hope that you will choose to answer as many questions as you can. This call may be monitored for quality assurance. May we begin?

RESPOND TO ANY QUESTIONS/CONCERNS AS NEEDED. REFER TO FREQUENTLY ASKED QUESTIONS AND ANSWERS.

YES............................................ 01 → END OF SCREENER. BEGIN INTERVIEW.

NO, NOT A GOOD TIME............ 02 → GO TO APPOINTMENT TAB

NO, REFUSED............................ 03 → Thank you for your time. TERMINATE.

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