PWS Attachment B - Screening Questionaire.pdf

VHA HFE Studies - Screening Questionnaire

Introduction

On behalf of the Veterans Health Administration and [CONTRACTOR], we thank you for your interest in participating in one of our upcoming studies. The purpose of these studies is to improve the services offered to Veterans by gathering their feedback on healthcare tools, such as mobile apps or websites.

We first need to ask you about 5 minutes’ worth of questions to ensure that you are a good match for our study needs.

Please note that all information and opinions you provide will be used solely for the purposes of selection and invitation to future paid studies sponsored by the Veterans Health Administration. If selected, you will be compensated between $25, $50, and $75 per study. If the study requires you to attend in person, you will also be reimbursed for mileage up to $25. The opinions and information collected will not become part of any permanent file and all reporting will be combined anonymously with the opinions and information of other Veterans from around the country.

In the coming months, a member of the study project team may contact you if you are selected to participate. Opportunities for involvement in these studies will come up a few times per year. Each study is different and you will have the opportunity to accept or decline an invitation based on your availability.

You will receive a $5.00 e-gift card via email for completing this questionnaire. You are required to submit an answer for every question, and some questions allow you to opt out of providing information.

You may quit this questionnaire at any time, but you must finish it to earn the e-gift card.

Please make sure to maximize your window and click on the "Next" button below to begin the survey.

The first set of questions is about your Veteran status.

• Do you have Veteran status?

• Are you an employee of the Department of Veterans Affairs?

• Do you volunteer at a VA facility?

The next set of questions is about the technology that you may use.

• Does your cellular (mobile) telephone have the ability to access the Internet, download applications (or apps) and send/receive e-mails?

• What is the operating platform for your smartphone?

• Approximately how many apps do you have installed on your smartphone?

• Do you have any U.S. Department of Veteran Affairs apps installed on your smartphone?

• Do you use a tablet device, such as an iPad or Samsung Galaxy Tab?

• Is this tablet a shared device in your household or is it for your primary use?

• Does the tablet that you use have a data plan, meaning you pay a per-month fee for internet access when not accessing a wireless network (wi-fi)? This would be similar to a data plan that a cellular telephone may have.

• What brand of tablet device do you own?

• Approximately how many apps do you have installed on your tablet?

• Do you have any U.S. Department of Veteran Affairs apps installed on your tablet?

Now thinking about desktop computers and laptops, what is your preferred computer operating system? (Select all that apply)

• Mac OS X

• Windows 7

• Windows 8

• Windows 10

• Linux

• Google Android

• VMware Fusion 6

• Google Chrome

• Haiku

• ReactOS

• Syllable

• SkyOS

• I don't use a computer

• Not sure

• Other (please specify)

Do you actively use the MyHealtheVet website? (www.myhealth.va.gov)?

• Yes

• No

How frequently do you use the MyHealtheVet website?

• Weekly or more often

• Monthly

• Once every other month

• A few times a year

• Once a year or less

What level of MyHealtheVet account do you have?

• Basic

• Advanced

• Premium

• Not sure

Do you use My HealtheVet for Rx (prescription) refills and/or do you use a commercial pharmacy system for medication refills (e.g., Walgreens, CVS)?

• Use My HealtheVet for Rx refills

• Only use a commercial pharmacy system

• Use both

• Prefer not to answer

Do you use VA or a commercial pharmacy system for medication refills (e.g., Walgreens, CVS)? [Check all that apply]

• VA for medication refills

• Commercial pharmacy system

• Prefer not to answer

• Use something else (please specify)

Do you use any other applications for ordering prescriptions or accessing your medical information online, such as myCVS On the Go or Target Healthful? If so, how often do you use such applications?

• Weekly or more often

• Monthly

• Once every other month

• A few times a year

• Once a year or less

• I do not use these types of applications

• Now just a few more questions about you.

Just a few final questions about you.

Have you previously participated in a usability test or served as a beta tester, or are you active in an online tech community or panel?

• Yes

• No

Do you participate in any Veteran Service Organizations (VSOs), such as Disabled American Veterans, or Veterans of Foreign Wars (VFW), or Iraq and Afghanistan Veterans Association (IAVA)?

• Yes

• No

In which branch of the military did you most recently serve?

• Army

• Navy

• Air Force

• Marine Corps

• Coast Guard

• Other (please specify)

In which era(s) did you serve in the military? (Check all that apply)

• World War II

• Early Cold War Era (1945 to 1949)

• Korean Conflict (1950 to 1953)

• Cold War Era (post Korean War) (1954 to 1963)

• Vietnam Era (1964 to 1975)

• Late Cold War Era (1976 to 1991) (Grenada, Beirut, Libya, Panama)

• Post-Cold War Era (1991 to 2001) (Persian Gulf War, Somalia, Haiti, Yugoslavia)

• War on Terrorism (2001 to present)

Do you have a Serviced-connected Disability?

• Yes

• No

What percentage is your disability rating?

• 0%

• 10%

• 20%

• 30%

• 40%

• 50%

• 60%

• 70%

• 80%

• 90%

• 100%

• Prefer not to answer

Do you utilize VHA (Veterans Health Administration) services for health care?

• Yes, currently

• Yes, but not in a long time (over 2 years ago)

• No

Are you currently accessing mental health care services through VA?

• Yes

• No

• Prefer not to answer

• What is your gender?

Are you under or over 50 years of age?

• Under

• Over

As part of their research efforts, the VA has an interest in interviewing female Veterans that are pregnant. Are you currently pregnant?

• Yes

• No, but planning/hoping for a pregnancy in the near future

• No

Are you currently using, or do you plan to use, prenatal healthcare services provided by the VA or paid or by the VA?

• Yes

• No

Do you plan to use healthcare services provided by the VA or paid for by the VA for your Labor, Delivery and Maternity care?

• Yes

• No

What is the highest level of education you have completed?

• Some high school

• High school graduate

• Trade school

• Some college

• College graduate

• Postgraduate work

• Prefer not to answer

Which of the following best describes your ethnic race or background?

• African American / Black

• Asian / Pacific Islander

• Caucasian / White

• Hispanic / Latino

• Native American

• Multi-Ethnic

• Prefer not to answer

• Other (please specify)

In which state do you currently live?

In what year were you born?

Closing Thank you for your time. If you have any questions about this survey or the work it will support, you may contact [CONTRACTOR POC] at [CONTRACTOR] by calling (NNN) NNN-NNNN, or e-mail [HIM/HER] at

[CONTRACTOR POC EMAIL].

As mentioned, the Veterans Health Administration, in collaboration with [CONTRACTOR], is looking for Veterans to participate in various usability studies in the upcoming weeks and months. These projects will either take place in person or via the Internet and will last 1 to 1.5 hours. We will contact you as opportunities to participate become available. You will be compensated between $25, $50 or $75 per project plus travel if required if you participate.

To thank you for providing answers to these questions today, please select a vendor from the following list, and we will send you a $5.00 e-gift card via email.

Thank you for completing our survey.

Please select a vendor for your $5.00 e-gift card.

• Amazon

• Target

• TGI Fridays

Into which of the following age ranges to you fall?

• Under 18

• 18-24

• 25-34

• 35-44

• 45-54

• 55-64

• 65-74

• 75 or older

[IF SCREENED OUT] Due to your status with the VA, you are not eligible to participate. Thank you for your time.

This concludes the survey. Thank you for your time.