Instructions for Front Cover
- Create a front cover for your survey. Include a user-friendly title and your own logo.
- As is appropriate to the approvals and protections established for your data collection, include text such as the following regarding the confidentiality of survey responses:
Example
Your Privacy is Protected. All information that would let someone identify you or your family will be kept private. {VENDOR NAME} will not share your personal information with anyone without your OK. Your responses to this survey are also completely confidential. You may notice a number on the cover of the survey. This number is used only to let us know if you returned your survey so we don’t have to send you reminders.
Your Participation is Voluntary. You may choose to answer this survey or not. If you choose not to, this will not affect the health care you get.
What To Do When You’re Done. Once you complete the survey, place it in the envelope that was provided, seal the envelope, and return the envelope to {INSERT VENDOR ADDRESS}.
If you want to know more about this study, please call {XXX-XXX-XXXX}.
Instructions for Format of Questionnaire
Proper formatting of a questionnaire improves response rates, the ease of completion, and the accuracy of responses.
- If feasible, insert blank pages as needed so that the survey instructions (see next page) and the first page of questions start on the right-hand side of the questionnaire booklet.
- Maximize readability by using two columns, serif fonts for the questions, and ample white space. The PDF version of the CCQM-PC v 2.0, accessible from the AHRQ Web site, is formatted in the suggested two-column layout.
- Number the pages of your document, but remove any headers and footers that may have been inserted solely to maintain version control during the formatting process—for example, footers that helped sponsors and vendors to distinguish among questionnaire versions across review cycles.
This document is in the public domain and may be used and reprinted without special permission. Citation of the source is appreciated.
Suggested Citation: Agency for Healthcare Research and Quality. Care Coordination Measure for Primary Care Survey. Prepared under Contract No. HHS290-2010-00005I. AHRQ Publication No. 16-0042-1-EF. Rockville (MD): Agency for Healthcare Research and Quality; 2016. http://www.ahrq.gov/carecoordination
This project was funded under contract number HHS290-2010-00005I from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The opinions expressed in this document are those of the authors and do not reflect the official position of AHRQ or the U.S. Department of Health and Human Services.
